Membership Application Form Raleigh-Wake County Dental Society » Member Directory » Member Registration This membership form is only for NEW Applications only. If you are renewing your membership. Please visit here. Membership Application and Dues Statement PLEASE NOTE: ALL MEMBERS (INCLUDING LIFE MEMBERS) MUST COMPLETE THIS FORM ANNUALLY. PLEASE HIGHLIGHT NEW OR RECENTLY CHANGED INFORMATION. Membership Year* Application TypeNew(Choose One)Name* First Middle Last Address* Street Address Address Line 2 City ZIP Code Business Phone*Business FaxHome PhoneCell PhoneEmail* Practice Website Dental Education (Dental School Attended/Degree)Advanced Graduate Education (Advanced or Specialty Training/School)Type of PracticeDental AnesthesiologyEndodonticsGeneral DentistryOral and Maxillofacial RadiologyOral and Maxillofacial SurgeryOral PathologyOrofacial PainOrthodonticsPediatric DentistryPeriodonticsProsthodonticsPublic HealthMembership Classifications(Please Check One) Active Member - A person who is licensed to practice dentistry in North Carolina and resides in Wake County or whose professional practice site is in Wake County may be elected to Active Membership... $380.00* Associate Member - A person who holds a professional dental degree and is currently practicing may be elected to Associate Membership... $380.00* Life Member - A dentist who has reached age 65 and has been a member of the Raleigh-Wake County Dental Society for the previous 10 consecutive years. Upon application in writing to the Treasurer, dues will be assessed at fifty percent (50%) of the regular Active Member fee. Life Members approved prior to December 6, 2018 will remain exempt from dues payment, however contributions and assessment payments are encouraged... $217.50* Disabled Active – A member in good standing who has incurred or developed a physical condition that renders the person incapable of performing clinical dentistry for an extended period of time or permanently. Application must be made in writing to the Executive Board. There is no fee for this classification... $85.00* Honorary/Emeritus – A dentist who has reached age 65 and has been a member of the Raleigh-Wake County Dental Society for the previous 25 consecutive years. Upon application in writing to the Treasurer, dues will be waived, however a $75 dinner fee is charged... $85.00* *An $85 voluntary contribution to the RWCDS Foundation is included. The Foundation is a 501(c)(3) organization and donations are tax-deductible. Among other dental health-related endeavors, the Foundation is supportive of Wake Tech’s Hygiene Assisting programs, Wake Smiles, Wake County’s Children’s Dental Health Month, UNC SOD, and Give Kids A Smile Day. Please increase or decrease the amount of your donation as you deem appropriate. Dues are due on or before January 1, 2021, and are considered late if not paid by February 1, 2021 PLEASE PAY YOUR DUES VIA PAYPAL OR A CHECK PAYABLE TO THE RALEIGH-WAKE COUNTY DENTAL SOCIETY AND MAIL TO: RALEIGH-WAKE COUNTY DENTAL SOCIETY c/o Kimberly Lee 2718 CREEK BEND CT GRAHAM NC 27253-8482 For additional information: Please contact the Administrative Assistant, Kimberly Lee [email protected] or (706) 551-0623NameThis field is for validation purposes and should be left unchanged.
