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 *
Your answer
Practice/Department Name *
Your answer
Preferred Mailing Address *
Preferred Mailing Address *
Your answer
Cell Phone # *
Your answer
Work Phone #
Your answer
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 *
Your answer
Payment Method *
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
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?
Auto-Renewal?
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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