New ALD Account
** Students — please provide copy of current student I.D.
Dental / Hygeine School
Specialty Graduate School Details
Please indicate your Standard or Advanced certification below:
(Must be official ALD-approved course. Must provide via mail or fax documentation of successful completion.)
(check all that apply)
Please indicate your profession/position (check all that apply)
Please select your specialty:
Please indicate whether you use any of the following advanced/high-tech systems or equipment in your practice:
Please list the lasers that you use regularly?
Please list each currently marketed or discontinued dental laser
Which laser procedures do you regularly perform? (Please check all that apply)
Please list each product or service (other than lasers) you currently market
Of which other organized LASER group(s) are you a corporate member? (e.g., national and regional laser societies, laser study clubs, etc.)
Of which other national dental societies/associations are you a corporate member/sponsor?
Please indicate the ADVERTISING CONTACT for your company.(Please Note: If mailing address/phone/fax or email is different from corporate office)
You may designate TWO additional representatives to receive WAVELENGTHS and other regular Academy mailings. Please list each name and title below.(Please Note: If mailing address/phone/fax or email is different from corporate office)
Representative #1 - Details
Representative #2 - Details
Please indicate names and titles of THREE individuals you would like listed as your company contacts on ALD's web site.(Please Note: If mailing address/phone/fax or email is different from corporate office)
Individual #1 - Details
Individual #2 - Details
Individual #3 - Details
Please provide a 40 WORD company and/or product profile to be used in your company listing for our website and promotional literature(Please Note: Copy should be descriptive in nature, not sales oriented. ALD reserves the right to edit copy)
Upon written notification requesting membership withdrawal received within 60
days of application, a refund will be issued less $150 administrative fee. No refunds will
be issued after 60 days of application.
9900 West Sample Road, Suite 400Coral Springs, FL 33065
Phone: 954.346.3776Toll Free: 877.527.3776Fax: 954.757.2598
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