Local Dental Society Resources

The forms below are provided for the convenience of the leadership of Local Dental Societies, who wish to update their society information with the national office, or pay their chapter’s required national dues online. For Society Profile information, you can also download a PDF version of the 2024 Society Profile & Delegate Form here.

Local Society Dues

2024 Society Profile & Delegate Form

Local Society Dues

Name(Required)

First Last

Email(Required)

Office Ph.

Fax

Home Ph.

Cell

Office Held(Required)

NDA Local Society(Required)

NDA State Society

Update Information

Local Society Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Description

2024 MEMBERSHIP DUES(Required)

Other Payment(Required)

Notes - Other Payment(Required)

Supporting Documentation (If Required)

Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 100 MB.

for Affiliate/International, Full-Time Faculty, Retired or Graduate/Resident Membership

NDA Legacy Fund

Total

Credit Card(Required)

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

2024 Society Profile & Delegate Form

Date

Society Name

EIN #

Street address, City, ST, ZIP Code

Person Completing Form

Primary phone number

Other phone number

Email address

Facebook Address

Instagram

Twitter

2024 Delegates: Please identify your delegates for the 2024 NDA Annual Convention. You may attach an additional sheet if necessary.

Please List Society Officers

Term Start Date

Please List Society Officers

Term End Date:

President

President - Elect

Vice President

Secretary (Corresponding/Recording)

Treasurer

Financial Secretary

Community Outreach Chair

Newsletter Editor

Geographic Area:

# of Society Members:

# of Potential Members:

General Population:

# of NDA Dues Paying Members :

# of Volunteer Members:

Dental Public Health Facilities:

Local Dental Schools:

Please complete the requested information regarding community outreach liaisons, activities, and media outlets.

Outreach Program Committee Contact Person:

Email Address:

Telephone:

Mailing Address:

Community Partners:

Sponsors:

Upcoming Scientific Meetings / Community Outreach / Special Events – The information you provide will help to promote the activities and accomplishments of our local societies in electronic and printed materials. Attach additional information if necessary.

Event – Description of activities

Date

Event – Description of activities

Date

Event – Description of activities

Date

Event – Description of activities

Date

Local media outlets for the African American markets (TV, Radio, Newspapers, Blogs)

TV – Include call letters

Contact Person

Radio – Include call letters

Contact Person

Radio – Include call letters

Contact Person

Newspaper

Contact Person

Blog

URL

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