Allied Health Tech Auxiliary

Requirements for Dental and/or Maxillofacial Prosthetic Technicians

1. Be licensed, registered or otherwise permitted by law to practice as a dental or maxillofacial prosthetic technician.
2. Be involved in patient care solely as directed or prescribed by licensed and qualified dentists.
3. Must be recommended for membership by one Fellow and a second Fellow or Associate Fellow.
4. Submit three patient case reports that demonstrate experience in providing some aspect of maxillofacial prosthetic technical procedures.
5. The applicant will present a paper or table clinic at an annual session meeting involving some aspect of maxillofacial prosthetic technical procedures.

The dental and maxillofacial prosthetic technician auxiliary will pay dues but is ineligible to vote or hold office.

Personal Information

Honorific
== choose one == Mr. Ms. Mrs. Dr.

First Name

Middle Name/Initial

Last Name

Nickname

Significant Other First Name

E-mail

Date of Birth

Gender
== choose one == m f other

Institution/University

Title/Position

Website

Please list all AAMP meetings and dates you have attended

Academic Training

	Institution	Degree	Year
Pre-Dental or Pre-Medical
Dental or Medical
Graduate

Post Graduate

List all short post-graduate courses in last five years (include course, institution, degree, year; one per line)

Specialty Board Certification

Certified?
 Y    N

Certification

Year

Fellow Program

Program

Year

Residential Program

Program

Year

Student Program

Program	Proposed Graduation Date
Institute	Department
Director	Director Email

Teaching or Hospital Appointments

List all teaching or hospital appointments (include institution, appointment, date; one per line)

Research Experience

List Research Experience (include project, grant source if applicable, and dates; one per line)

Please list papers, posters, essays, and workshops presented by you at dental or other professional meetings and the dates

List memberships in professional and scientific organizations (ADA, etc.) and offices held

Names of two Active Fellows of the Academy from whom the Secretary may obtain an endorsement

Name 1

Name 2

What is your purpose in wanting to join the Academy and in what capacity do you believe you can best serve the Academy?

Privacy Information

Show in member directories?
 visible    hidden

Who can view member details?
 public    members only    administrators only

Do you consent to receive email communications from us, regarding your membership?
 Y    N

Yes, I agree to abide by the Constitution, By-Laws and other rulings of the Academy as well as such changes and amendments as may thereafter be properly adopted.

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