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1. Name __________________________________________________________________________________
 (Last) (First) (Middle Initial) (Degrees)
2. Complete Mailing Address __________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
(Area Code - Phone) (Area Code - Fax) (Email)
3. Date of Birth _____________________________ How many years in practice? ___________________
4. Have you previously applied for membership in the American Equilibration Society?
Yes  No When? ______________
Have you previously been a member of the American Equilibration Society?
Yes No When? ______________
5. Dental/Medical education ____________________________________________ Year __________________
(Institution)(Degree)
6. Graduate education _________________________________________________ Year __________________
(Institution)(Degree)
7. Are you a member of the American Dental Association? Yes No
Are you a member of another national Dental Association? Yes No Name _____________________
8. Licensed in what States/Provinces/Countries: ____________________________________________________
9. Do you have a recognized specialty? Yes No Specialty _________________________________
10. What percentage of your practice is devoted to treatment of TMJ, Muscle or Occlusal Dysfunction? _________
11. University Affiliation (Teaching or Research) ___________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________ Full-time Part-time
12. Other Affiliations (Hospital, Government, Military, etc.) ___________________________________________
_________________________________________________________________________________________
_________________________________________________________________ Full-time Part-time
13. Postgraduate Education: __________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
14. Publications and Presentations: _____________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
15. Participation in Professional Organizations: (Includes offices and committee chairmanships) ______________
_________________________________________________________________________________________
_________________________________________________________________________________________
16. What is your purpose in wishing to join the society? ______________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
17. If accepted to membership in the American Equilibration Society,
I agree to abide by the constitution, By-laws, and other rulings of the Society.
______________________________________________________ Date ___________________________
(Signature of Applicant)
18. PAYMENT: Check Enclosed Money Order Enclosed Credit Card
Credit Card Number:_________________________________________________ Expiration Date: _________
Signature:_________________________________________________________
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