AADEJ logo Membership Application

Note: Your dues must accompany this application. Also, if you are applying for Publication Membership you must enclose 4 copies of your publication for review by the Eligibility Committee.

Name:   
Address:

City:      
     State:           Zip Code:
Phone:   
     Fax:
e-mail:   


Title:
Editor           Business Manager           Former Editor           Author           Executive Director
       
Teacher        Other (explain):

Type of membership you are applying for:Publication ($190)  Publication Assoc. ($75)    Student Pub. ($45)
                                                                      
Individual ($75)    Affiliate/International ($75) Retired ($25)
Publication Qualification:
Publication Title:
Publisher (sponsoring organization or company):

Type of Publication:
State       Component         Specialty         Foreign         Commercial
Alumni      Student                 Fraternal         Other (describe briefly):

Frequency of issue circulation:

Are you now affiliated with a publication?  Yes   No

     If NO, have you been affiliated with a publication in the past?  Yes    No

Does your publication carry advertising? Yes     No

     If YES, does it have an officially adopted advertising code?    Yes   No  
          (If YES, please enclose advertising code)


Does the sponsoring organization exercise complete control over the editorial and advertising content? Yes      No

Has the editor or publication been a prior member of AADEJ?   Yes     No

Dental organization memberships: