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Membership Application
First Name
Date of Birth
Middle Name
Last Name
Gender
Male
Female
Place of Birth Street Address
Place of Birth Street Adresss Line 2
Place of Birth Postal / Zip code
Marital Status
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Required
Married
Not Married
Do you prefer we use your Business or Home mailing address?
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Business Address
Home Address
Business Contact Info Place of Employment
Business Address
Business Address Line 2
Business Address City
Business Address Postal / Zip code
Business Address Region/State/Province
Business Address Country
Country
Business Website
Business Email
Office Phone
Business Office Phone
Personal Street Address
Personal Street Address Line 2
Personal City
Personal Postal / Zip code
Personal Region/State/Province
Personal Country
Country
Personal Email - this is where your application confirmation will be sent
Cell Phone
Personal Cell Phone
Home Phone (if applicable)
Personal Home Phone (if applicable)
Educaton/Professional Practice Info: Current Degree (s) - Check all that apply
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DO
DPM
DMD
MD
PhD
DDS
DCM
PharmD
Other
Primary Specialty
Secondary Specialty
Board Certified?
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Required
Yes
No
State(s) in which Professional Licensed/Professional School Attended
Practice/Group First Name
Practice/Group Last Name
Practice/Group Contact's Phone Number
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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Membership Dues ($)
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Regular Member - $325
Assoc. Member - $165
Resident Member - $50
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