Membership Application Form - New DAPA Member | The Dental Assistants Professional Association

Thank you for considering membership to the Dental Assistants Professional Association.

Please make sure you have read all the information about membership here before continuing.

Membership Types

Please select the appropriate membership level below. You will have a chance to review your selection and the corresponding fees on the next page prior to being charged.

Membership *

Platinum Membership - $ 140.00

Professional (Full) - $ 95.00

Please renew my membership automatically.

Total Amount

I want to contribute this amount every year

Your recurring contribution will be processed automatically. You will receive an email receipt for each recurring contribution.

Your Registration Info

Email Address *

Title *

First Name *

Last Name *

Home Address *

Home Address 2

Home Address 3

Home Suburb *

Home State *

Home Postcode *

Job Title *

Work/Employer

Work Address

Work Address 2

Work Suburb

Work State

Work Postcode

Home Phone

Work Phone

Mobile Phone

Preferred Communication Method

Phone
Email
Postal Mail
SMS
Fax
Mobile Phone
Work Phone

Confidential Additional

Date of Birth *

Preferred Newsletter Format

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Membership Application Form - New DAPA Member