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Membership Application
First Name
Date of Birth
Middle Name
Last Name
Gender
Male
Female
Place of Birth
Postal / Zip code
Marital Status
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Required
Married
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Do you prefer we use your Business or Home mailing address?
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Business Address
Home Address
Business Contact Info
Business Address
City
Postal / Zip code
Region/State/Province
Country
Country
Business Website
Business Email
Office Phone
Personal Contact Info
City
Postal / Zip code
Region/State/Province
Country
Country
Personal Email - this is where your application confirmation will be sent
Cell Phone
Home Phone (if applicable)
Educaton/Professional Practice Info: Current Degree (s) - Check all that apply
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Required
DO
DPM
DMD
MD
PhD
DDS
DCM
PharmD
Other
Primary Specialty
Secondary Specialty
Board Certified?
*
Required
Yes
No
State(s) in which Professional Licensed/Professional School Attended
Practice/Group Contact
Practice/Group Contact's Phone Number
Practice/Group Contact's Email
CHECK THAT YOU UNDERSTAND THE FOLLOWING: After clicking the submit button below, you will be taken to a payment page to complete your membership. Your membership is not complete until both your application and the applicable payment have been received. Student memberships do not require payment. On the payment page, please manually enter your debit or credit card details. Saved credit card information stored on your device or browser is not permitted.
I hereby attest to the accuracy of the foregoing information and apply for membership in the Arkansas, Medical, Dental and Pharmaceutical Association
Signature
Signature Date
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required
Membership Dues ($)
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Regular Member - $325
Assoc. Member - $165
Resident Member - $50
Testing - $1
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