FDS Membership Application

Membership Application (Federal Dental Services)

Join us. Start the application process online today by searching for your profile, using your name and dental school graduation year, or your ADA number.

You can also download and mail in a PDF application.

Have questions? We'd love to help:

call us at 800.621.8099
email membership@ada.org

* indicates required field.

Search Options

First Name

Last Name

Dental School Graduation Year

OR

ADA Number

OR

Prefer to mail in your application?

Personal Information

Last Name

*Required

First Name

*Required

Middle Initial

Date of Birth

Gender

Male

Female

Spouse Name

U.S. Mobile Phone

Federal Email Address

*Required

Address Information

Home Address

Street Address

*Required

Country

*Required

State/Province

*Required

City

*Required

Postal Code

*Required

U.S. Phone Number

*Required

Office Address

Street Address

Country

State/Province

City

Postal Code

U.S. Phone Number

Fax Number

Preferred Address Type

*Required

Branch of Service/Verification of Service

Service Branch

*Required

*Required Other:

Agency:

In-Service Date

*Required

Verification of Service

*Required

Federal Address Email Provided

Cover Page from Your Federal Contract

Attach File Only Word/PDF file less than 1MB size is allowed

If you cannot attach a copy, fax a copy to the American Dental Association at 312-440-3542 or mail it to: American Dental Assn, Attn: FDS Membership, 211 E Chicago Ave, Chicago, IL 60611 United States.

Previous Education

Country of School Attended

*Required

Dental School

*Required

Other:

*Required

Graduation Date

Month:

Year:

*Required Type of Degree:

Advanced Education Program

School/Hospital/Clinic

Speciality

Program Start Date

Month:

Year:

Program End Date

Month:

Year:

Other :

*Required

License Information

Please review the dental licensure information shown below. Please add or correct information by typing over the information provided.

Current Licenses

Lic. Number:

State:

Add:

Below are your added Licenses		State	Lic State Value

Survey Questions

1. Please review the following 2 statements and indicate how well each statement describes you.

Does not describe me at all

Describes me completely

1. Helping people is the #1 reason I became a dentist.

2. Every day I seek excellence in the diagnosis and treatment of complex problems.

2. How proud were you at each of the following moments in your dental career?

Not at all proud/Not applicable

Extremely proud

1. Graduating from dental school.

2. When a patient showed extreme gratitude after a procedure.

3. Helping a specific patient that was in need.

4. Successfully treating an extremely complex case for the first time.

3. Now, we would like to learn more about your work and personal beliefs. After you read each statement, please indicate how well each statement describes you.

Never or definitely no

Always or definitely yes

1. If a coworker gets a prize, I would feel proud.

2. The well-being of my coworkers is important to me.

3. To me, pleasure is spending time with others.

4. I feel good when I cooperate with others.

Membership Application (Federal Dental Services)

OR

OR

Survey Questions

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