Membership Status Change

Membership Status Change Request

The Academy of General Dentistry (AGD) recognizes that members’ circumstances change throughout their careers. To assist members through these transitions, the AGD offers various membership status options to current members in good standing. In the event your situation does not fall under any of these categories, you may submit a special request for consideration by the Membership Council to membership@agd.org.

If you wish to apply for a status change, please complete this application and provide a one-page letter explaining your situation as supporting documentation. This information will be provided to the Membership Council for their review.

Full Name

AGD Member ID Number

AGD Constituent

Please select the option that best represents your circumstances.

Leave of Absence

A member who has temporarily left the practice of dentistry for at least six (6) months for reasons including, but not limited to family leave, family tragedy, or personal health problems. Members under this status will have reduced dues for one year, with annual re-application for a period not to exceed three consecutive years.

Hardship

A member who has suffered a catastrophic property and/or financial loss due to a federally declared natural disaster, local natural disaster, fire, accident, or other event. Members under this status are exempt from paying all dues associated with AGD membership for one year. Hardship waivers are limited to one-time only approval and will not be approved for multiple years.

Total Disability

A member of the AGD who is totally disabled and no longer earning income from the performance of service as a member of a dental school faculty, as a dental administrator or consultant, or as a practitioner of any form for which a license to practice dentistry or dental hygiene is required. Members under this status are exempt from paying all dues associated with AGD membership. A signed physician statement attesting to the disability must be completed and submitted with this application.

Retired Membership

A member that has been an active member in good standing with AGD for ten (10) or more who is no longer earning income from the performance of service as a member of dental school faculty, as a dental administrator or consultant, or as a practitioner of any form for which a license to practice dentistry or dental hygiene is required.

If applying for retired status, please indicate date of retirement:

I hereby attest that I am eligible for the above dues waiver request, and that my license to practice dentistry has not been revoked or suspended.

I have attached a one-page typed letter supporting my request for a change in status (all requests).

I have attached a signed physician’s statement attesting to my total disability (disability requests only).

Please upload relevant documents.

Select a file to upload.

Signature and Date