RENEW TODAY & ADD YOUR STAFF
Hispanic Dental Association – 2015 Professional Group Membership Application
ONLINE MEMBERSHIP APPLICATION AVAILABLE ON HDA WEBSITE AT www.hdassoc.org
NOTE: Group Key Contact — serves as liaison with the Hispanic Dental Association for your Group Membership — fills out this
application form and return it to the HDA at the address or email below.
Key Contact Full Name:
______________________________________________________ Degree: __________________
Practice/Department Name: ________________________________________________________________________________
E-Mail Address:
______________
Mailing Address:
______________
Mailing Address:
______________
City:
___________________________ State: ____________ Zip:_________________ ______________
Daytime Phone #:
_______________________________ Website: _______________________________________
Professional Type:
____________________________Specialty Type:_______________________________________
Primary Practice Setting:
________________________________________________________________________________
Membership Selection:
____$50 Supporting Member _____$0.00 Open Membership____$40 Local Chapter Affiliation
Member #2 Full Name:
____________________________________________ Degree(s): __________________________
E-Mail Address:
______________
Professional Type:
____________________________Specialty Type:_______________________________________
Membership Selection:
____$50 Supporting Member _____$0.00 Open Member ship____$40 Local Chapter Affiliation
Member #3 Full Name:
____________________________________________ Degree(s): __________________________
E-Mail Address:
______________
Professional Type:
____________________________Specialty Type:_______________________________________
Membership Selection:
____$50 Supporting Member _____$0.00 Open Member ship____$40 Local Chapter Affiliation
Professional Type Options:
Administrator
Dean
Faculty
Dentist-General
Dentist-Specialist
Hygienist
Oral Surgeon
Supplier
Technician
Dental Assistant
Other: (Fill in)
_____________________________________________________
Specialty Type: Circle One
Endodontics
Oral & Maxillofacial Pathology
Orthodontics
Oral & Maxillofacial Radiology
Pediatrics
Oral & Maxillofacial Surgery
Periodontics
Public Health Dentistry
Prosthodontics
Other: (Fill in)
Primary Practice Setting: Options
Academia
Administration
Community Health Clinic
Hospital
Dental Industry Supplier
Private Practice
Federal Government
Research
Armed Services
State Government
Public Health
Other:
HDA Foundation Contribution for student scholarships
(Tax Deductible Under US IRS Rules)
Amount: $
Discounted Subscription to American Journal of Dentistry
 U.S. Address $55.00 (Non-HDA members pay $105)
Member #4 Full Name:
____________________________________________ Degree(s): __________________________
E-Mail Address:
______________
Professional Type:
____________________________Specialty Type:_______________________________________
Membership Selection:
____$50 Supporting Member _____$0.00 Open Member ship____$40 Local Chapter Affiliation
1111 14th Street, N.W.  Suite 1100  Washington D.C.  20005
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Canada or Mexico $85.00 (Non-HDA members pay $135)
All Other Countries $95.00
 Yes- We would like to sponsor a new student
HDA chapter of 10 student members for $150
Tel. 202.629.3628  Fax: 202.629.3802  www.hdassoc.org
Membership Categories: Select Most Appropriate
Supporting Member  $50.00 in Annual Dues
Open e-Membership
Benefits:
 Official Certificate of Membership
 Annual Meeting discounts
 Free classified advertising on HDA Website and Newsletter
 Resource information of patient education materials and forms in Spanish by request)
 Recognition Awards at the Annual Meeting
 Committee service opportunities
 Subscription to the quarterly HDA Newsletter print edition
 Subscription to HDA National e-Brief
 Access to exclusive capital funding for HDA member’s practices
 Discounted Subscription to American Journal of Dentistry
Benefits:
 Annual Meeting discounts
 e-subscription to the quarterly HDA Newsletter
 Subscription to HDA weekly National e-Brief
 Access to exclusive capital funding for HDA member’s
practices
 Discounted Subscription to American Journal of Dentistry
Select the Local Chapter you wish to be a part of.
(Local Chapter Dues: $40.00)
[National HDA membership is a
requirement of Chapter membership]
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Austin HDA
Eastern Washington HDA
Greater Chicago HDA
Greater Houston HDA
Greater San Antonio HDA
Los Angeles HDA / Latinos for Dental Careers
HDA of San Diego/Baja California
Massachusetts HDA
New York HDA
North Texas HDA
Washington DC HDA (pending)
Merchandise:
Quantity X Amount =
Total
$5.00 Blue HDA T-Shirt (100% Preshrunk Cotton)
Amount/Size: ____M ____L ____XL ____XXL ____XXXL
X $5.00
= $________
$10.00/each HDA Lapel Pin
X $10.00
= $________
*Add $5 for orders under 4 items.
Please complete and return this
application by mail, fax, or email to the
HDA National Office – information
below. THANK YOU!
Group Membership Total
Local Chapter Total
Foundation Donation Total
AJD Subscription Total
Student Chapter Sponsor
Merchandise Total
Check processing fee $10.00
TOTAL
$
$
$
$
$
$
$
$
Credit Card Information:  VISA  MasterCard
Expiration Date:
Security Code:
Credit Card #: __________________________________
Name on Card: _________________________________
Billing Address: _________________________________
______________________________________________
If sending a Check or Money Order, add a $10 processing
fee – make payable to the Hispanic Dental Association.
Check/Money Order #:_____
Hispanic Dental Association
1111 14th Street, N.W. Suite 1100, Washington D.C. 20005
Fax: 202.629.3802 Email: hispanicdental@hdassoc.org