MEMBERSHIP REGISTRATION Please fill-out this online membership application to join iADS. If you have any questions about membership, contact us at admin@theiads.org or call 800.919.1964. iADS Member Registration Applicant Name* First Middle Last Whom May We Thank for Referring You? Degrees:* Education credentialsNPI Number:* US Member International Enter your NPI Number (US - Members Only)* To find your NPI number and to get more information, CLICK HEREInternational Member - Upload Your Specialty Certificate (bottom of form)Birthdate:* MM slash DD slash YYYY Gender:* Male Female Specialty/Affiliation* Endodontics Oral Maxillofacial Pathology Oral Maxillofacial Radiology Oral Maxillofacial Surgery Orthodontics & Dentofacial Orthopedics Pediatric Dentistry Periodontics Prosthodontics Corporate Technical Rep (Affiliate) General Dentist (Non-Specialist) Other Dental School Education Dental School AttendedBeginning Date MM slash DD slash YYYY Dental School Beginning YearEnding Date MM slash DD slash YYYY Dental School Ending YearDegree Obtained Degree ObtainedSpecialty School Attended Post-Graduate School AttendedBeginning Date MM slash DD slash YYYY Specialty Training School Beginning YearEnding Date MM slash DD slash YYYY Specialty Training School Ending YearSpecialty Cert. Obtained Specialty Certificate ObtainedAre you presently in a Residency Program?* Non-Resident Resident If you are currently a resident, when will you graduate? School AttendingBeginning Year MM slash DD slash YYYY Start dateEnd Year MM slash DD slash YYYY Expected end dateCertificate Expected (student letter required) *Name of Practice Company or School (Full-Time Faculty)* Provider Specialty* Primary Office / Home (if Resident) Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Office Phone*Office FaxCell Phone*Office Email* Personal Email Address* Email Address for all Communication* Office Email Personal Email Website / URL Our community will grow with specialists that you can personally recommend.Are you willing to provide colleagues that we can contact for membership?* Yes No Name of Colleague First Last Email of Colleague Office PhoneCell PhoneLocation Second ColleagueName of Colleague (2) First Last Email of Colleague (2) Office Phone (2)Cell Phone (2)Location (2) Third ColleagueName of Colleague (3) First Last Email of Colleague (3) Office Phone (3)Cell Phone (3)Location (3) HiddenSection BreakCommittee Interest: Please list what committee(s) of iADS you would like to be part of.For membership approval you must submit the following documents:International Members - Please Provide Specialty CertificateResidents - A letter in English on official letterhead from your program director indicating start date and anticipated date of graduation.Please upload all appropriate documents here Drop files here or Select files Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 256 MB, Max. files: 3. A photocopy of your specialty certificate or school letter.*If you haven’t uploaded copies of your required credentials, please submit them as soon as possible or else your application will remain pending.CAPTCHANameThis field is for validation purposes and should be left unchanged.
