Provider Membership Application

Organization Information

Address(Required)

Primary Contact Information (Designated Representative)

Role(Required)
Please select the option that best describes you.

Please Note: You may add up to two additional contacts for your organization. These individuals will also have access accounts made for the membership portion of the website.

Secondary Contact Information

Role(Required)
Please select the option that best describes you.

Tertiary Contact Information

Role(Required)
Please select the option that best describes you.

Organization Information

Annual CAD Public Program Revenue (most recent year)(Required)
Are you a CAD Provider in good standing?(Required)

Committee(s) your organization would like to join – indicate Yes/No

Government Affairs (GAC):(Required)
Industry Affairs (IAC):(Required)
Membership and Communications (MCC):(Required)

Committee Appointee(s) Roster 1

Committees (check)

Committee Appointee(s) Roster 2

Committees (check)

Membership Billing Info

Address of Organization/Person for Invoice:(Required)

Finalize

Please Note: By becoming a member, you agree to support our mission and follow our governance processes.

When you submit this form, you will be redirected to payment options. You must be fully paid to access membership benefits on the website. If you have questions, please contact Dr. Sheila Riggs sriggs@umn.edu or Dr. Michael Helgeson mhelgeson@appletreedental.org
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Signature(Required)
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