Transfer to NYSDA Application

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Transfer Application

ADA Number

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

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First Name

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Last Name

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Transferring From

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Enter your previous state association

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Referred By ADA Member

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First & Last Name - ADA # preferred

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Birth Month

Birth Day

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Birth Year

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Gender

Female
Male
Prefer Not to Answer

Home Address

Address Line 1

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Address Line 2

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City

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State

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Zip Code

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Phone Number

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Please include area code

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Cell Phone Number

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Please include area code

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Email Address

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Please provide a non-.edu email address

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Preferred Mailing Address

Home
Work

Office Address

(Used to determine local dental society)

Address Line 1

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Address Line 2

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City

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State

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Zip

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Business Phone Number

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Please include area code

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Fax Number

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Please include area code

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Business Email Address

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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

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Degree

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Grad Year

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Residency

Hospital

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

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Specialty

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Enter "GPR" if applicable

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Start Year & Grad Year

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

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NYS License Number

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6-digit number only

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Date Licensed

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Expiration Date

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Leave blank if unsure

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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#

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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.

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