Please use this form to complete your Life Membership Application.  Submitted Applications will be reviewed by the Board at their next regularly scheduled Board meeting.  Certificates are mailed twice per year.

There are 4 Categories for Application.  Please review the following prior to beginning your application. 

No Fee Applications 

Category 1. Active Diplomates for 20 years or more, who are completely retired from the practice of Dentistry, Dental Public Health, or Public Health.  

Category 2. Active Diplomates for 10 years or more, who are age 65 years or older and completely retired from the practice of Dentistry, Dental Public Health, or Public Health. One-Time Fee Applications  

Fees are listed in the Fee Schedule within the Diplomate's Guide--you will be invoiced following application.

Category 3. Active Diplomates for fewer than 10 years, who are completely retired from the practice of Dentistry, Dental Public Health, or Public Health.  

Category 4. Active diplomate retired from the full‐time practice of Dentistry, Dental Public Health, or Public Health; currently working in Dentistry, Dental Public Health, or Public Health part-time (<200 hours per year / 0.1 FTE).