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 n n n n n n n n n n 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 • [email protected] • Visit ICOI’s website for complete information: www.icoi.org FOR MEMBERSHIP QUESTIONS, PLEASE CALL TOLL-FREE: 1-888-449-4264
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