WDA Membership Application

WDA Membership Application

Please submit your application. The application will be reviewed by the Board of Directors for approval. You will be notified about your approval status after the meeting. If you have any quesitons in the meantime, please contact office@wadenturist.com
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What type of membership are you applying for?*

Denturist Active Member: $500 for first year as a memberSecond Year Post-Grad: $500First Year Post-Grad member: $200Non-Denturist Associate Member: $25 per yearStudent member: Free
Company/Business Name*
Denturist Member's Name*
School Currently Enrolled At*
Anticipated Year of Graduation*
Year of Graduation*
Phone Number*
Please enter a valid phone number.
Current WA Denturist License #*
Date of Initial WA License:*

MonthDayYear
Date
Are/were you licensed or certified in another state or province?*

YesNo
If yes, list the state and license #
Please list any denturist schools/programs you have attended and the dates of attendance:
Additional Comments:
I understand that in order to become a member of the WDA, my membership application is subject to approval by the board. By submitting my application, I agree to abide by and uphold the ideals and bylaws of the Washington Denturist Association, in its endeavor to unite, protect and further the profession. I understand that my dues need to be current in order to receive the benefits of membership. Reduced, prepaid rates apply only to memberships paid in full during the month of January for that year. If dues go unpaid for 90 days, my membership is terminated as a result of non-payment, that I will still be held responsible for payment of any past due amount. If following termination due to non-payment, any reinstatement of membership would require prepayment of one year's dues.
Signature

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