LDDS 2022-23 Membership Registration

London & District Dental Society, c/o 409 High Street, London, Ontario N6C 4L6

T: 226-663-7479 F: 226-213-4150 E: ldds@rogers.com

LDDS MEMBERSHIP APPLICATION 2022 - 2023

Name*

Prefix

First Name

Last Name

Office Address

Address Line 1

Address Line 2

City

Province

Postal Code

Office Phone Number

Office Fax Number

Home/Cell Phone Number

Personal Email Address

Alternate/OfficeEmail Address

Home Mailing Address

Address Line 1

Address Line 2

City

Province

Postal Code

Graduated From:

Graduation Year:

Specialty

Specialty School

Specialty Grad Year

Accepting New Patients?

Yes No

Languages Spoken in Your Office?

LDDS MEMBERSHIP FEES

LDDS HST # 797595519

Current ODA Membership is required for ALL CATEGORIES

Membership Fees: Select the option that applies to you

ACTIVE LDDS MEMBER: $375.00 + hst $48.75 = $423.75

423.75

2nd Year Grad @ 50%: $188.00 + hst $24.44 = $212.44

212.44

3rd Year Grad @ 75%: $282.00 + hst $36.66 = $318.66

318.66

Associate Member (registered with another component society) $ 425.00 + hst $55.25 = $480.25

480.25

Affiliate Member (no registration certificate, registered with another ODA society) $ 425.00 + HST $55.25 = $480.25

480.25

Non Registered, Retired Member - Membership Fees Waived - Dinner fees apply

Non Registered, Retired Member - No registration fee

Graduate Student & GPR Members - Membership Fees Waived - Dinner fees apply

Graduate Student & GPR Members - No registration fee

HONOURARY MEMBERS - by Nomination - Membership & Dinner fees waived

Honourary Member - No registration fee

Payment