Transfer to NYSDA Application

Transfer Application

ADA Number

If you do not know your ADA, please leave blank.

First Name

Last Name

Transferring From

Enter your previous state association

Referred By ADA Member

First & Last Name - ADA # preferred

Birth Month

Birth Day

Birth Year

Gender

Female
Male
Prefer Not to Answer

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number

Please include area code

Cell Phone Number

Please include area code

Email Address

Please provide a non-.edu email address

Preferred Mailing Address

Home
Work

Office Address

(Used to determine local dental society)

Address Line 1

Address Line 2

City

State

Zip

Business Phone Number

Please include area code

Fax Number

Please include area code

Business Email Address

Practice Information

Is the practice a professional corporation?

Yes
No

Do you also practice at other locations?

Yes
No

Practice type

General Practice
Practice Limited To

Practice type

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

Yes
No

Education

Dental School

Dental School Name

Degree

Grad Year

Residency

Hospital

If you did not complete a residency, simply enter N/A

Specialty

Enter "GPR" if applicable

Start Year & Grad Year

Please list and describe any additional hospital, internship, residency and military affiliations, past and present. Include dates started, completed and any relevant documentation.

NYS License Number

6-digit number only

Date Licensed

Expiration Date

Leave blank if unsure

Are you currently registered with the NYS Dept. of Education?

Yes
No

Have you been affiliated with dental associations previously?

Yes
No

Please describe current or previous affiliations, with dates and ID/ADA#

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?

Yes
No

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

Yes
No

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?

Yes
No

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.

Transfer Application

Home Address

Office Address

Practice Information

Education

Background

Stay Connected

General Information

Sections

Resources

Transfer Application

Home Address

Office Address

Practice Information

Education

​Background

Stay Connected

Background