Application Form

2021-2022 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:
–>Active Members: $425
–>Retired Members (If previously active member): $60 per dinner meeting, $150 all day
–>Recent Dental School Graduates:
Year Graduated: 2019 ($350), 2020 ($250), 2021 ($150)
–>Dental Students: 1 complimentary dinner meeting per year, $150 all day meeting

Please Return this Form with Payment to:
THE MAIMONIDES DENTAL SOCIETY
Attn: Dr. Pierre Cartier
1701 16th St NW, #715
Washington, DC  20009

How did you year about us? _______________________________________________________________________________________
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