ALD: New ALD Users

User/Member Type

New Member – JOIN NOW!
New Corporate Member – JOIN NOW!
Professional (no membership required) – FREE!
Corporate Professional (no membership required) – FREE!
Patient – FREE!

Personal Information

First Name:

Last Name:

M.I.:

State/Province:

Address:
Address (opt.):
City:
Zip Code:
Country:
Company/Institution:

Contact / Website Information

E-mail:			Home Phone:			Fax:
Office Phone:			Cell Phone:			Web Site URL:

Education Information

Dental / Hygeine School

Name of School:
City:
State:
Country:
Graduation Year:

Specialty Graduate School Details

Name of School:
City:
State:
Country:
Graduation Year:

Certification / Training Information

Please indicate your Standard or Advanced certification below:
(Must be official ALD-approved course. Must provide via mail or fax documentation of successful completion.)

Intro Certification

Date	Course Location	Wavelength/Device	Course Instructor	Manufacturer

Standard Certification

Date	Course Location	Wavelength/Device	Course Instructor	Manufacturer

Dental License Information

Dental Lic.
Number(s)

State

Country

Company Product(s) or Service(s)

(check all that apply)

Air Abrasive System	CAD/CAM System	Computer Imaging	Electronic Anesthesia
Filmless Digital X-Ray	Intraoral Camera	Laser Fibers	Laser Protective Eyewear
Lasers	Other Laser Accessories	Perio Charting	Periodonal Diagnostics

Practice / Profession Information

In what year did you begin dental practice?

Please indicate your profession/position (check all that apply)

Dental Assistant	Dental Hygienist	Dentist	Hygienist
Industry Rep	Office Manager	Office Staff	Physician
Researcher/Scientist	Student	University Faculty

For Dentists Only

Please select your specialty:

Primary Specialty	Sub-Specialty 1	Sub-Specialty 2

Please indicate whether you use any of the following advanced/high-tech systems or equipment in your practice:

Air Abrasion System		Intraoral Camera(s)	CAD/CAM System
Perio Charting		Computer Imaging	Periodontal Diagnostics
Filmless Digital X-Ray		Laser Assisted Endo	Laser Caries Diagnosis
Other	If Other, please indicate:

Dental Lasers / Procedues

Wavelength	Manufacturer	Laser Model	Year Began Use

Products or services other than lasers

Please list each product or service (other than lasers) you currently market

Product/Service	Description

Relations

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)

Additional Representatives

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

Company's Individuals

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

Company Profile

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)

Associations / Affiliations / Committees

Please specify any hospital or academic affiliation(s) you may have: (Please indicate city, state & country)
In which other organized LASER group(s) are you involved? (e.g., regional laser societies, laser study clubs, etc.)
Of which National/Regional Dental Societies/Associations are you a member? (Please indicate whether you hold office)
Are you interested in serving on a volunteer ALD committee?	Yes No
If you answered yes, please list preference, if any:

How did you hear about the Academy?

Please let us know how you found out about the Academy of Laser Dentistry?

Mailing List

	Dentist - $395 Dentist Applies to any licensed practicing dentist. Dentist members have full voting rights and are eligible for elected office.		Associate - $150 Associate Includes dental auxiliaries, hygienists or office managers interested in obtaining knowledge about laser dentistry. Associate members are non-voting.		Student - $50 Student Includes dental or auxiliary students or residents in an accredited dental school program (non-voting). Please provide copy of student I.D. **Grad Year:
	Affiliate - $150 Affiliate Includes any non-dental professional, scientist or physician qualified and recognized in his/her respective field and not eligible for membership in other categories. Affiliate members are non-voting.		Non-Practicing - $150 Non-Practicing Includes any retired or disabled dentists. This non-voting category is not open to dentists currently working with a manufacturer or vendor.

Laser Soft Tissue Surgery	Laser Etching	Laser Sulcular Debridement
Laser Composite	Laser-Assisted Implants	Laser Tooth Whitening
Laser TMT fo Aphthous/Herpes Lesions	Laser Assisted Endo	Laser Caries Diagnosis
Laser Desensitization	Laser Caries Removal/Cavity Prep	Other

Credit Card Type:	Card Number:
Name on Credit Card:	Expiration Date:	/
CVV2 Code:

NEW ALD Users/Members Registration

Corporate Professional Registration (without Full Membership) is FREE

Professional Registration (without Full Membership) is FREE

Patient/Public Registration (without Full Membership) is FREE

Quick Links

Do you use a laser in your practice or laboratory?	Yes No
If 'Yes', in what year did you begin using a laser?

Phone:		Fax:
Address 1:		Address 2:
City:		State/Province:
Zip Code:		Country:

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