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Documentation of the board certification is required
Please submit to the Ninth District.

Please list and describe hospital, internship, residency and military affiliations, past and present(Include dates started, completed and documentation)

Were you ever convicted of a felony or disciplined by a state board for dentistry or a state regents board?
(If yes, please explain in the field below)

Current or previous affiliations with dental associations (describe, note dates and ID/ADA#)

Were you ever rejected, deferred or suspended by a state or component society of the ADA?(If yes, explain in the field below)

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 Ninth District 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 Ninth District Dental Association, New York State Dental Association and the American Dental Association.

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