AMERICAN DENTAL HYGIENISTS’ ASSOCIATION

                                DIVISION OF MEMBER SERVICES

                                              444 N. MICHIGAN AVE., SUITE 3400, CHICAGO, IL  60611 

                                  800-243-2342 • (312)440-8900 • FAX 312-467-1806 • www.adha.org

 ______________________________________                Circle Your Credential:

Name (Last, First, Middle Initial)                                                                           RDH    GDH   LDH   Other:______

 ______________________________________

Maiden Name

 __________________________________             ___________________________________

Street Address                                                                           Daytime Telephone (include area code)

 __________________________________               __________________________________

City/State/Zip Code                                                                 Evening Telephone (include area code)

 Dental hygiene school attended:_________________State:_________Year of Graduation:_____

 To qualify for membership, you must have been granted a license to practice dental hygiene.

 Current License #:__________________________ State:_______________

 Highest educational level attended:  ‪Certificate    ‪Associate   ‪Baccalaureate    ‪Master’s  ‪Doctorate

 Annual Dues:

 National Dues:                          $ 170.00

 Constituent Dues:                   $   65.00                                               Utah Components       

                                                                                                                          01-Sale Lake Component         

Component Dues:                   $  10.00 (UT 01/02/03/04)         02-Northern Component

                                                                                                                          03-Central Component

TOTAL:                                       $ 245.00                                                04-Southwestern Component

 $6.00 and $5.00 of the annual ADHA membership dues are allocated for subscriptions to the Journal of Dental Hygiene

and Access, respectively.  Dues are not deductible as charitable contributions for federal income tax purposes. 

They may be deducted as a business expense.

 Method of Payment:

I am enclosing a check payable to ADHA for the amount of my annual dues as determined above.

Please charge my annual dues as determined above to my credit card.

(Complete the credit card information below.)

 Visa  ‪Mastercard

 Card Number:_____-_____-_____-_____ Expiration Date:____/ ____

 Name as it appears on the card: (Please Print)____________________________   

 Signature:_________________________________  Date:_________________