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AMERICAN DENTAL HYGIENISTS’ ASSOCIATION DIVISION OF MEMBER SERVICES444 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:_________________
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