ABP Life Diplomate Application Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Thank you for your interest in Life Diplomate or Active Life Diplomate status. Life Diplomate Membership is a distinguished membership status offered to Diplomates who have demonstrated lifelong support of the specialty of Prosthodontics and to The American Board of Prosthodontics. This status reflects the dedication from our most esteemed members. Your application will be reviewed and voted on in December of your application year. In preparation, please complete the form below to indicate and attest to your qualification for Life Diplomate or Active Life Diplomate status, per the ABP bylaws.

ABP Bylaw: Section 13.4 Life Diplomate Status

A Diplomate with ten (10) years of good standing and having totally retired from compensated teaching, practice, or related dental activities is eligible to apply for Life Diplomate or Active Life Diplomate status. Additionally, a Diplomate reaching the age of 70 years or having 35 continuous years of good standing, is eligible to apply for Life Diplomate or Active Life Diplomate status. Upon review and approval of an application by the Board of Directors, Life Diplomate or Active Life Diplomate status will be awarded and a certificate will be issued.

PLEASE NOTE: As a Life Diplomate you will not be charged annual dues; however, the tradeoff is that you will no longer have membership login access nor a listing in the ABP online directory, and you will not be eligible for verification or recertification. As an Active Life Diplomate, you will be charged $100 annually for your dues. This will allow you to have membership login access and a listing in the ABP online directory; however, you are not eligible for recertification or verification. If you need to retain eligibility for recertification and verification, please maintain your active Diplomate status.

Email *

First Name *

Last Name *

Mailing Address *

City *

State *

Zip *

Contact Phone *

I qualify for life membership based on at least one of the three criteria below. Check off each statement that applies and provide the applicable date below. *

I am a member in good standing for more than 10 years and I have totally retired from compensated teaching, practice, or related dental activities.

I am a member in good standing and I have reached the age of 70.

I am a member in good standing and I have had 35 years of continual membership with the ABP.

Required

Date of Retirement

YYYY

Date of Birth *

YYYY

Date of Initial Certification *

YYYY

Attestation *

I attest that I qualify for life diplomate status based on the criterion/criteria selected above

Required

Life Diplomate or Active Life Diplomate Status *

I am applying for Life Diplomate status. I understand that as a Life Diplomate I will not be charged annual dues; however, the tradeoff is that I will no longer have membership login access nor a listing in the ABP online directory, and I will not be eligible for verification or recertification.

I am applying for Active Life Diplomate status. I understand that as an Active Life Diplomate, I will be charged $100 annually for my dues. This will allow me to have membership login access and a listing in the ABP online directory; however, I will not be eligible for recertification or verification.

Required

Diplomate Status *

I understand that if I need to resume eligibility for recertification and verification, that I will have to request to reactivate Diplomate status and pay the full fee for annual dues.

Required

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Forms