Full Name:

Last: First:

Phone Numbers:

Office: FAX:
Home:

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E-Mail:

Business/Office Address:

Street:
City:    Prov: pcd

Other Dentists in your Group:

Associates:

Membership Types and Fees:

This application is for the following membership:

Active Member - $325.00 annual fee,
     dues paid After Aug. 31, 2006.

Active Member - $275.00 annual fee,
     dues paid Before Aug. 31, 2006.

Senior Member - $275.00 annual fee,
     dues paid After Aug. 31, 2006.
    (Applicant requires 30 yrs practice and
     5 yrs previous CDDS membership)

Senior Member - $225.00 annual fee,
     dues paid Before Aug 31., 2006.
    (Applicant requires 30 yrs practice and
     5 yrs previous CDDS membership)

New GRAD - $225.00 annual fee.
     dues paid After Aug. 31, 2006.

New GRAD - $175.00 annual fee.
     dues paid Before Aug. 31, 2006.

Retired Member - No lecture or annual fees.
    ($20.00 charge per meal at lectures/courses.)

Non-member and Miscellaneous fees:

Individual lectures for Non-member Dentists -
    $175.00 per course, including coffee and lunch.

Individual lectures for Staff Members -
    $40.00 per course for each person.
    (Lunch is not available.)

Donation to CUPS for Open Wide
    $20.00 suggested donation.
    (Make cheque out to CUPS/OPEN Wide.)

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After submission you will be contacted, via E-Mail, for payment information.