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.
* Required
Email address
*
Your email
Applicant Full Name
*
Your answer
Practice/Department Name
*
Your answer
Preferred Mailing Address
*
Choose
Home
Practice
Department
Preferred Mailing Address
*
Your answer
Cell Phone #
*
Your answer
Work Phone #
Your answer
Specialty Type
*
Choose
General Dentistry
Endodontics
Pediatrics
Periodontics
Prosthodontics
Orthodontics
Oral Maxillofacial Surgery
Faculty
Other
Member Category: National Dues & Local Dues = Total
*
Dentist: $200 & $50 = $250
Dental Hygienist: $150 & $40 = $190
Dental Assistant: $100 & $30 = $130
Dental Administrator: $100 & $30 = $130
Resident: $30 & N/A = $30
Lab Technician: $200 & $50 = $250
Insitution Membership: $400 & N/A = $400
Would you like to donate to HDA Foundation for future student scholarships?
*
$20
$50
$100
No donation
Other:
Enter Total Amount to be Paid
*
Your answer
Payment Method
*
Credit Card via Square Reader (full amount). Collected by GSAHDA Officer
Pay online at
www.gsahda.org
. Select "Make a Donation", then "HDA Membership Dues"
Credit Card info to be sent to National HDA.
Money Order or Check payable to Hispanic Dental Association
Cash
If Applicable, Check # & Amount
Your answer
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
Choose
Visa
Mastercard
Discover
American Express
Name on Credit Card
Your answer
Credit Card #
Your answer
Credit Card Expiration Date (MM/YY)
Your answer
Credit Card Security Code
Your answer
Billing Address with Zip Code
Your answer
Pay in Full or Split into 3 Payments?
Pay in Full
Split into 3 Payments ($10 Processing Fee)
Clear selection
Auto-Renewal?
Yes
No
Clear selection
Who referred you?
Your answer
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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