International Association for Orthodontics
Membership Application

To insure security of your credit card payment, please print this form, fill in all blanks, and mail or fax it to the IAO.

For Developing Countries (Poland, Russia, China, Philippines, Chile, Brazil, Mexico, Malaysia, Indonesia, and other developing countries)

Name:   
Address1: 
Address2:
City:  
State/Province: Zip/Postal:  
Country:  
Phone (Business):
Fax Number: 
E-mail Address:
Graduate of: 
Grad. Year & Degree: 
Member of: ADA NDA  CDA   Other  
Membership: New Renewal 
  Annual Membership:  US $106            
One time processing fee for new members:        US $ 30
TOTAL:                       US $136
 
Credit Card: Visa  MasterCard  Discover    American Express
Account Number: Exp. (Mo/Yr):  
Signature: ______________________________________Date:_________  
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To insure security of your credit card payment, please return this to:

The International Association for Orthodontics
750 N. Lincoln Memorial Dr #422
Milwaukee, WI  53202  USA
Fax: +414.272.2754