Academy of Laser Dent istry
Fellowship & Mastership
Applicat ion
Select an application type (must check one)
Fellowship of the Academy of Laser Dentistry
Mastership of the Academy of Laser Dentistry
Completed application forms must be submitted electronically to memberservices@laserdentistry.org as an
attachment. Your completed application including the letter of professional reference must be received by the
Academy office by December 31st.
Personal Information
Last Name
Date of birth
First Name
City/Country of birth
Middle Name
Maiden Name
Country of citizenship
Gender
Female
Male
Contact Information
Work mailing address
Work phone
Work fax
Work e-mail
Home phone
Home fax
Permanent e-mail
Work
Permanent mailing address
Home
Education
List institutions attended (above secondary school level), starting with the most recent.
Educational institution
Dates
attended
From – To
(month/year)
Degree
received
(or expected)
Academy of Laser Dentistry
Attention: Fellowship & Mastership Program
9900 W. Sample Road, Coral Springs, FL 33065 USA
Phone: 954-346-3776 or Toll Free 1-866-LASERS6 (527-3776); Fax: 954-757-2598
E-mail:memberservices@laserdentistry.org; Web: www.laserdentistry.org
Date degree
received
(or expected)
Fields of study
Major
Minor
Fellowship/Mastership Application
Page 1 of 4
Applicant’s Name:
Date:
Please describe any honors, fellowships, career-related activities, publications, etc.
Occupational Experience
Year Began Practicing Dentistry
Type of Practice (e.g. General Practice,
Pediatric, Orthodontics, Periodontics, etc.)
Sole Practitioner/ Group Practice
Website address
Personal Statement
Please write a narrative describing you as an individual. It should deal with your personal history; influences on
your career choice; the educational, cultural, and other opportunities you have enjoyed; and the ways in which
these experiences have affected your professional life goals. Please limit this statement to 500 words in English,
and include this statement as part of your application.
Academy of Laser Dentistry
Attention: Fellowship & Mastership Program
9900 W. Sample Road, Coral Springs, FL 33065 USA
Phone: 954-346-3776 or Toll Free 1-866-LASERS6 (527-3776); Fax: 954-757-2598
E-mail:memberservices@laserdentistry.org; Web: www.laserdentistry.org
Fellowship/Mastership Application
Page 2 of 4
Applicant’s Name:
Date:
Letters of Reference
For your application to be complete, original letters of professional reference must be submitted by a
professional dental colleague of equivalent degree stature who possesses first hand knowledge of your dental
laser clinical expertise. Please provide contact information for the person you have asked to provide a letter of
reference on your behalf. Download the form called Professional Reference Form and have the person providing
the reference complete the form and e-mail it to memberservices@laserdentistry.org. The reference form is
available on the ALD website.
Reference’s phone
Reference’s full name
Reference’s title
Reference’s e-mail address
number
IMPORTANT: All components of the application package must be received by the Academy office by December
31st. Late or incomplete applications will not be considered. Review of your application will begin when all
components are received successfully.
Certification Confirmation
Provide the data below and attach copies of your certificate(s) to allow proper verification. Please make sure all
data is provided. Applications will not be reviewed without this required information.
Level of Certification
Date(s)
Instructor
Device Tested On
Introductory Course
Standard Proficiency
Advanced Proficiency
Educator Course
Financial
Amount Due:
$275 Initial Fellowship Application
Payment Type:
Check No:
Please make check payable to the Academy of Laser
Dentistry and mail it to the Academy of Laser
Dentistry PO BOX 8667, Coral Springs, Florida 33075.
$450 Initial Mastership Application
Credit Card
Yes, I will pay by credit card. Please send me an invoice
for the appropriate application fee. Note to Applicant:
Do not send credit card information in this form as
email is not secure. We will send an invoice to you.
~ Laser Continuing Education Tracking Form follows on the next page ~
Academy of Laser Dentistry
Attention: Fellowship & Mastership Program
9900 W. Sample Road, Coral Springs, FL 33065 USA
Phone: 954-346-3776 or Toll Free 1-866-LASERS6 (527-3776); Fax: 954-757-2598
E-mail:memberservices@laserdentistry.org; Web: www.laserdentistry.org
Fellowship/Mastership Application
Page 3 of 4
Laser Continuing Education Tracking Form
Use this form to provide all recognized continuing education hours spent in the discipline of laser dentistry
for Fellowship (minimum 50 for initial application and 25 CE’s for ongoing renewal) or Mastership (minimum
of 100 for initial application and 50 CE’s for ongoing renewal). Applicable CE includes all ADA, CERP or AGDPACE laser lectures or courses. When using ALD Annual Conference Continuing Education Credits please
make sure to provide the total CE hours obtained by your attendance. If providing international coursework
be sure to provide enough information about the laser educational program to allow sufficient review to be
counted towards the total required hours. You may scan any certifications and/or continuing education
documents and attach them to your electronic application submission via email to
memberservices@laserdentistry.org. (Attach additional documents, if needed).
Date
Course Title
Instructor
Completion Code
Hours
I hereby confirm that the information provided in this application is truthful, complete, and up-to date.
Applicant Signature:
Academy of Laser Dentistry
Attention: Fellowship & Mastership Program
9900 W. Sample Road, Coral Springs, FL 33065 USA
Phone: 954-346-3776 or Toll Free 1-866-LASERS6 (527-3776); Fax: 954-757-2598
E-mail:memberservices@laserdentistry.org; Web: www.laserdentistry.org
Date:
Fellowship/Mastership Application
Page 4 of 4