Application Form

2019-2020 THE MAIMONIDES DENTAL SOCIETY APPLICATION
(for further information contact Dr. Pierre Cartier:  (202) 790-7863  pierrecartierdmdmph@outlook.com)
Name_______________________________________________Email_____________________________________
Address:_______________________________________________________________________________________
City_________________________________________________State__________________Zip:_______________
Tel (W)____________________________________________Cell________________________________________
Dues:  Check appropriate circle.
O Active Dentist: $425           O Students: Free for dinner meeting;  O $150 for All-Day              O Retired Member: $50 per meeting; O $150 All-Day
New Dentists:  O 2019 Grad: $150      O Guests:  Dentists – first dinner-mtg free;
O 2018 Grad: $250          (subsequent dinner mtg – full dues apply)
O 2017 Grad: $350                       O All-Day – full price
O Support Staff / Non Dentists: $80 / dinner-mtg; $150 for All-Day

Please Return this Form with Payment to:  THE MAIMONIDES DENTAL SOCIETY
% Dr. Pierre Cartier
1831 Belmont Road NW #404
Washington, DC  20009
How did you year about us? _______________________________________________________________________________________
_______________________________________________________________________________________

 

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