UCLA Periodontics Information Center

Membership Information | Application for Membership | Meeting Schedule

Membership Application

Print out application form, complete, and return to:

Western Society of Periodontology
9010 Reseda Boulevard, Suite 204
Northridge, CA 91324

Phone: (818) 993-5093 or (800) 367-8386

Please print legibly
ID#

Last Name
Degree (DDS, DMD, RDH, etc.)

First Name, Middle Name
Phone
Mailing Address

Street
City, State or Province, Zip
I hereby apply for membership in the Western Society of Periodontology in one of the following categories. I certify that I am qualified for this category in accordance with the conditions stated on the opposite page. Enclosed are the appropriate fees and dues.
ACTIVE*
ASSOCIATE
NONRESIDENT
AFFILIATE
STUDENT
Dues $180 $150 $125 $90 $25
Initiation Fee $15 $15 $15 $15 none
Total $195 $165 $140 $105 $25
*If you are seeking active membership, a copy of certification form your postdoctoral periodontics program is required with this application.
Please complete the following information:
Dental Practice
Limited Practice
Periodontics
Other ____________________
General Practice
Related Health Discipline (non-dentist)
Hygienist
Assistant
Other______________________
 Advanced Education in Periodontics



School, Degree, Date

Student (include copy of student I.D.)
Dental
Undergraduate
Graduate
Dental Hygiene

School


Graduation Date



Signature


Date


Top of Page

Membership Information | Application for Membership | Meeting Schedule