ABP Life Diplomate Application Form
Thank you for your interest in Life Membership status. Your application will be reviewed and voted on at the next full board meeting. In preparation, please complete the form below to indicate and attest to your qualification for Life Membership per the bylaws.

Bylaw: Section 13.4 Life Certificate. A Diplomate with ten years of good standing and having totally retired from compensated teaching, practice, or related dental activities is eligible to apply for Life Diplomate status A Diplomate reaching the age of 70 years or having 35 continuous years of good standing is also eligible to apply for Life Diplomate status. Upon approval by the Board of Directors, a “Life Certificate” will be issued. Questions about “related dental activities” will be addressed by the Board of Directors.

PLEASE NOTE: As a Life Member, you are not be charged annual dues; however, the tradeoff is that you are no longer listed as a member within the ABP online directory and you will not be eligible for verification or recertification.
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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. *
Required
Date of Retirement
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/
DD
/
YYYY
Date of Birth *
MM
/
DD
/
YYYY
Date of Initial Certification *
MM
/
DD
/
YYYY
Attestation *
Required
A copy of your responses will be emailed to the address you provided.
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