Application Form

2022-2023 THE MAIMONIDES DENTAL SOCIETY APPLICATION
For further information contact Dr. Ali Fassihi:  (202) 293-9804 (FassihiDental@gmail.com)

Name_______________________________________________Email_____________________________________
Address:_______________________________________________________________________________________
City_________________________________________________State__________________Zip:_______________
Tel (W)____________________________________________Cell________________________________________

Dues:
–>Active Members: $425
–>Retired Members (If previously active member): $60 per dinner meeting, $200 all day meeting
–>Recent Dental School Graduates:
Year Graduated: 2020 ($350), 2021 ($275), 2022 ($200)
–>Dental Students: 1 complimentary dinner meeting per year, $200 all day meeting

Please Return this Form with Payment to:
THE MAIMONIDES DENTAL SOCIETY
Attn: Dr. Ali Fassihi
2021 K St., NW
Suite 822
Washington, DC 20006

How did you year about us? _______________________________________________________________________________________
_______________________________________________________________________________________