Fillable FULL ASSOCIATION MEMBERSHIP APPLICATION

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FULL ASSOCIATION MEMBERSHIP APPLICATION

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9-20
FULL ASSOCIATION MEMBERSHIP
APPLICATION
Yes, we are interested in becoming a member of the IFDH.
Contact Information
Please print in English
Organization __________________________________________________________________________
Address _____________________________________________________________________________
City ___________________________ State _______________________ Zip/Postal ________________
Country _____________________________________
Phone ___________________________________ Fax ___________________________________
Contact: First Name _______________________ Last Name ___________________________________
Title ____________________________ Email _______________________________________
# of Hygienists in: Country_________ Organization___________
Delegates to IFDH to be:
- First Name ______________ Last Name _______________________ Email ______________________
- First Name ______________ Last Name _______________________ Email ______________________
Please notify us if either of the two representatives above change.
See pages 2-3 for Required Attachments and Payment Options
→→
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For More Information, Contact:
• Peter Anas, Executive Director director@IFDH.org or Phone: 240-778-6790
Send Completed Forms to:
The International Federation of Dental Hygienists
100 South Washington Street, Rockville MD 20850, USA
OR Fax to: 240-778-6112
9-20
Page 2
IFDH Full Association Membership Application
-------------------------------------------
Required Attachments
Please include with your application ALL of the following information
in English:
Copy of the Statutes, Constitution and By-Laws of the national dental hygienists association.
Declaration that the applicant organization officially supports the Human Rights Statement of the
International Federation of Dental Hygienists on your official letterhead signed by the President.
List of legislated professional duties provided for patient care (please attach separate sheet)
Documentation that the applicant organization is the official national association which represents
the registered/licensed dental hygienists in that country e.g. registering authority, Labour
Department or other Government Agency.
One-time $125 (US) application fee (see page 3 for payment options).
Education: You may attach a separate sheet answering these questions:
• How many education programs for dental hygienists are there in your country?
• Which level of educational institution? e.g. (University, Community College, Training School,
Hospital). Please specify number and type.
• Qualifications attained e.g. Diploma, Certificate, Degree etc
• Details of curriculum to include course content (subjects, hours) and length of course.
• What are the pre-requisites for dental hygiene education?
e.g. secondary school, dental assisting.
For IFDH Use Only: Approval by Membership Committee Date _____________
9-20
Page 3
IFDH Full Association Membership Application
-------------------------------------------
Payment ($125 USD)
Bank Cashier's Check or Money Order in $US (Make payable to IFDH)
Mail to the address at the bottom of this page
Transfer from your bank to: Sandy Spring bank, 17801 Georgia Ave, Olney, MD, 20832, USA
Via one of the following:
ACH Transfer (preferred): Routing #055001096; Account #1758449501
Or
Wire Transfer:
Receiving Bank: Wells Fargo Bank N. A. San Francisco
--> SWIFT CODE: WFBIUS6S
--> ATTN: Foreign Exchange – Jeff Shopoff
For Further Credit To:
Sandy Spring Bank, 17801, Georgia Ave, Olney, MD 20832, USA -->
ABA #055001096
For Final Credit To
: International Federation of Dental Hygienists --> Account #1758449501
Name of your bank:
Branch:
Address:
Account: Sort Code:
Transfer date/reference:
Credit Card (Fax to +1.240.778.6112 or Enter information below, scan and email to membership@ifdh.org)
MasterCard Visa American Express
Cardholder's Name (print as it appears on card):
Credit Card #:
Expiration Date: Security Code (on back of card):
Cardholder's Signature:
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FULL ASSOCIATION MEMBERSHIP APPLICATION

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Completed 31 December 2021

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