MembershipApplication - International Congress of Oral

U.S. Membership
INTERNATIONAL CONGRESS OF ORAL IMPLANTOLOGISTS
MembershipApplication
EMPOWERING IMPLANT TEAMS WITH COMPREHENSIVE TECHNICAL AND PATIENT EDUCATION WORLDWIDE
NAME
AGD #________________
(As you wish it to appear on membership certificates, website listing, etc.)
First_________________________________ Initial(s)___________ Last_________________________ Degrees__________________
ADDRESS
Practice/Business Name___________________________________________________________________________________________
Office Address__________________________________________________________________________ Suite_____________________
City___________________________________________________ State_________________________ Zip_____________________
Telephone ______________________________________________ Fax __________________________________________________
E-mail_____________________________________________________________________________ Date of Birth ______________
http://www.
Web Address:_________________________________________________________________________________________________
Home Address____________________________________________ City_________________________ State_______ Zip__________
Cell____________________________________________________ Personal E-mail_________________________________________
Primary Address: Office Home (for membership website listing, publications and membership mailings)
EDUCATION
Dental School___________________________________________ Degree(s)________________________ Date rec’d________________
Technology School________________________________________ Degree(s)________________________ Date rec’d________________
Graduate School__________________________________________ Degree(s)________________________ Date rec’d________________
Specialty________________________________________________ Boarded?
Endodontist
Generalist
Oral & Maxillofacial Surgeon
Yes
No
Periodontist
Prosthodontist
Lab Technician Industry Personnel Full-Time Faculty Member
EXPERIENCE IN IMPLANT DENTISTRY
Implant continuing education hours in last 3 years: _____________
Experience in implant dentistry:
Involvement with implant dentistry:
Academic
less than 10 cases
Surgery
25–50 cases
Prosthetics
more than 100 cases
Periodontics/Maintenance
Technology
Other_____________________________________________________________________________
HOW DID YOU LEARN ABOUT THE ICOI?
Member referral (specify)_________________________________________________
Publication
rev. 4/15
Course __________________________________
E-mail
Internet
Direct mail
Other ______________________________________
(over)
ICOI U.S. Membership Application continued
ANNUAL U.S. MEMBERSHIP DUES INCLUDE:
n Bi-monthly/Mobile journal, Implant Dentistry available on iPhone, iPad, eAlerts and online full text of
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every article since 1992
Monthly complimentary webinars that are also archived online via www.dentalimplants.com
ICOI Concepts - shared digital knowledge via clinical updates and pearls Multiple national and international implant symposia (member discounts)
Exclusive MEMBERS ONLY websites - archived webinars, ICOI Concepts, practice resources,
1600 implant definitions, educational tools, and more...via www.icoi.org and www.dentalimplants.com
ICOI’s Glossary of Implant Dentistry II and CD-ROM - comprehensive guide to implant terminology online access via www.icoi.org
International certification program: Fellowship, Mastership and Diplomate credentials
Multiple prosthetic patient consent and communication forms to use in your practice daily
Quarterly ICOI World News
Professional and Patient Education - www.dentalimplants.com. Patient knowledge increases case acceptance,
valuable link to ICOI members’ practices
Two (2) certificates of membership - ICOI and Implant Prosthetic Section (IPS)
MEMBERSHIP CATEGORY SELECTION
ANNUAL MEMBERSHIP DUES
Valid for 12 months
(Please check the appropriate category)
CATEGORY I Dental Practitioner. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $350.00
CATEGORY II Full-Time University Faculty/Military. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200.00
CATEGORY III Laboratory Technicians, Research or Industry Personnel, Recent Graduate
(valid for 3 years post training). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150.00
CATEGORY IV Pre-doctoral or Graduate Student. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $100.00
projected graduation date: ____________
TOTAL AMOUNT ENCLOSED $_____________
PAYMENT INFORMATION:
Checks: Please make checks payable to the ICOI in US funds and mail to the address below
Credit Cards: Please complete the following information and fax both sides of this form to: (973) 783-1175
MasterCard
Visa
American Express
Card #_______________________________________________ Exp. Date___________ CVV No.______________
Signature_______________________________________ Date_______________ Billing Zip Code_______________
RETURN THIS APPLICATION WITH YOUR MEMBERSHIP DUES TO THE ICOI CENTRAL OFFICE:
55 Lane Road, Suite 305 • Fairfield, NJ 07004 • p: (888) 449-4264 / (800) 442-0525
f: (973) 783-1175 • membership@icoi.org • Visit ICOI’s website for complete information: www.icoi.org
FOR MEMBERSHIP QUESTIONS, PLEASE CALL TOLL-FREE: 1-888-449-4264