AAMP New Member Application


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Member Overview / Summary
Contact Info Email Address needs to be updated:
Contact Info Mailing Address needs to be updated:
Contact Name:
Membership ID:
Contact Email Address:
Membership Classification:
Current Amount Due: $        
Make a Donation:
Contact information made available on the AAMP Find a Member tab:
Member Classification
Member Classification applying for *



Login Information
How did you hear about the AAMP?
Username: *
Password: *
Confirm Password: *
Residential Contact Information
Title:
First Name/Given Name/Forename: *
Last/Surname/Family Name: *
Significant Other First Name:
Significant Other Last Name
Country: *
Address 1: *
Address 2:
Address 3:
City: *
State/Province/Region:
Zip/Postal Code:
Telephone Number (include country code):
Email Address: *
Business Contact Information
Title:
First Name/Given Name/Forename:
Last/Surname/Family Name:
Country:
Address 1:
Address 2:
Address 3:
City:
State/Province/Region:
Zip/Postal Code:
Telephone Number (include country code):
Facsimile Number (include country code):
Business Website: http://
Email Address:
Uncheck the following box if you do not want to be listed on the AAMP Find a Member tab*  
Education & Credentials Information
Year Member Joined the AAMP: 2019
American Board of Prosthodontics Certification Status - Certified Yes or No (check for Yes):
Year Member Became certified by the American Board of Prosthodontics:
Residency Program from which Member Graduated:
Year of Residency Program Graduation:
Fellowship Program from which Member Graduated:
Year of Fellowship Program Graduation:
For Student Applicants Only:
Program Name:
Program Institution:
Program Department:
Country:
Address 1:
Address 2:
Address 3:
City:
State/Province/Region:
Zip/Postal Code:
Proposed Graduation Date
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RadDatePicker
Open the calendar popup.
Program Director:
Program Director Email:
Member Photos

(Note 1): Photo file extension cannot contain UPPER CASE characters (e.g. on your computer, richt click & rename yourfile.JPG to yourfile.jpg
(Note 2): Photo upload works best if your photo name does not contain any spaces or "special keyboard characters", please try to name with only English alphabet or numbers.


Select photo to upload:  

  Is Main PhotoPhoto NameUploaded
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Member Registration Payments
Membership Dues for 2019

                     
Maxillofacial Foundation Donation: $50.00 (optional)       
$100.00 (optional)     
$200.00 (optional)     
$300.00 (optional)     
Enter an amount:      $
Credit Card Information
Total Amount Owed *
$
Card Number *
Card ID/CCV * (3 or 4 digit number on back of card)
Card Expires *
Name on Card * First   Last
Billing Street Address *
Billing Postal Code *
 
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(Administrative Use Only!)
Username:
Password:
Payment History
Amount PaidDate
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Donation History
Donation AmountDate
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Make a Donation
Credit Card Information
Donation Amount * $
Card Number *
Card ID/CCV * (3 or 4 digit number on back of card)
Card Expires *
Name on Card * First   Last
Billing Street Address *
Billing Postal Code *
 



(Administrative Use Only!)
Username:
Password:
Member Classification Change Request.
Fill out your comments below about why you wish to change. Click [Request Change] next to the Classification below that you wish to change to. The Membership Committee will review your request for consideration.
Comments:
 Classification
Affiliate Fellow (Annual Dues: $325)
Resides outside of the US/Canada
Allied Health Tech Auxiliary (Annual Dues: $285)
Associate Fellow (Annual Dues: $400)
Applicant has completed an ADA accredited prosthodontic program
Is a licensed dentist in the country in which they practice and retain citizenship.
Is a member in good standing in the ADA or an equivalent organization in which they practice and retain citizenship.
Student Member (Annual Dues: $0)
Student must be currently enrolled in a resident or student program and requesting to change membership to student status.
Online Journal Access Order History
Journal YearOrdered
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