HDA Professional Membership Application
Application for membership into Hispanic Dental Association (HDA) and Greater San Antonio HDA.
Full dues run from January to December 2020.
Not the application for students or BOLD members.
Email address *
Applicant Full Name *
Practice/Department Name *
Preferred Mailing Address *
Preferred Mailing Address *
Cell Phone # *
Work Phone #
Specialty Type *
Member Category: National Dues & Local Dues = Total *
Would you like to donate to HDA Foundation for future student scholarships? *
Enter Total Amount to be Paid *
Payment Method *
If Applicable, Check # & Amount
If credit card option selected, please proceed to Square Reader or enter your credit card information below to be processed by HDA National Office.
Payment by Credit Card
Name on Credit Card
Credit Card #
Credit Card Expiration Date (MM/YY)
Credit Card Security Code
Billing Address with Zip Code
Pay in Full or Split into 3 Payments?
Clear selection
Auto-Renewal?
Clear selection
Who referred you?
Thank you for your membership and contribution to HDA & GSAHDA. We are looking forward to a great year! Make sure to add Greater San Antonio Hispanic Dental Association on Facebook for the latest updates.
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