Give the Gift of Membership – Registration

Give the Gift of Membership - Registration Form

Name(Required)

First Last

Primary Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

If you are a practicing dentist, what city do you practice in?

Email(Required)

Phone(Required)

Do you know an incoming freshman dental student you'd like to sponsor? If so, please share their name here:

First Last

Do you give your approval for the student to contact you at this number?(Required)

Yes

Are you willing to answer any questions the dental student may have about the profession?(Required)

Yes

Please enter the number of students you are willing to sponsor ($122 each): (Required)

Price: $122.00

Total

Select your payment method:(Required)

Check

Credit Card

Please make check payable to:
Minnesota Dental Association

Mail check to:
Attn: Gift of Membership
Minnesota Dental Association
1335 Industrial Blvd., Ste. 200
Minneapolis, MN 55413

Credit Card

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

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