Transfer Application

If you do not know your ADA, please leave blank.
Enter your previous state association
First & Last Name - ADA # preferred
Gender

Home Address

Please include area code
Please include area code
Preferred Mailing Address

Office Address


(Used to determine component eligibility)
Please include area code
Please include area code

Practice Information

Is the practice a professional corporation?

Do you also practice at other locations?

Practice type

Are you board certified? (Documentation of board certification is required. Please submit proper paperwork to your local dental society.)

Education

Dental School
Residency
If you did not complete a residency, simply enter N/A
Enter "GPR" if applicable
6-digit number only
Leave blank if unsure
Are you currently registered with the NYS Dept. of Education?

Have you been affiliated with dental associations previously?

​Background

Were you ever convicted of a felony or misdemeanor or disciplined by a state board for dentistry, state regents board, other governmental agency, or other dental or professional organization?

Are you currently under investigation by any licensing body, governmental agency, or dental or other professional organization, which could lead to disciplinary action?

Were you ever disciplined or had an application for membership rejected, deferred or suspended by a state or component society of the ADA, or other dental or professional organization?

   

By submitting this application, I hereby state that I will conduct my practice in accordance with the accompanying Code of Ethics, which I have read. If at any time I should violate the Code of Ethics, it is understood that my membership may be forfeited in the Component Dental Society, New York State Dental Association and the American Dental Association. If elected to membership, I agree to comply with all By-laws, Codes of Ethics, and other Rules and Regulations of the Component Dental Society, New York State Dental Association, and the American Dental Association. I attest that all the above information is true to the best of my knowledge.
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