Join ICOI: U.S. Membership Application

Please fill out as much information as possible. Once you have filled out all the information, please press the "Review My Information" button below to review and confirm all your information. If you prefer, you may print or download ICOI's U.S. membership application as a pdf file, click here. Once you have reviewed your information, you can send your information securely to ICOI where your membership will be processed within 1-2 weeks. Thanks for joining ICOI! required = *

*First Name Initial(s) *Last Name Degree(s) Prac/Bus Name *Address Suite *City *State *Zip *Telephone Fax *E-mail Web Home Address City State Zip Phone Fax E-mail Undergraduate/Technology Degree   Date rec'd Dental School Degree   Date rec'd Post Doctoral/Graduate   Degree   Date rec'd *Specialty/Area of Practice Choose One General Dentist Oral & Maxillofacial Surgeon Periodontist Prosthodontist Laboratory Technician Industry Representative Other Board Certified Yes No Experience in Implant Dentistry Implant continuing education hours in last 3 years: Experience in implant dentistry: less than 10 cases 10-25 cases 25-50 cases more than 50 cases *Involvement with implant dentistry: Surgery Prosthetics Technology Periodontics/Maintenance  Other Annual U.S. Membership Includes: Quarterly subscription to our peer reviewed journal, Implant Dentistry Quarterly subscription to ICOI World News, our international societal newsletter International certification program:  Fellowship, Mastership and Diplomate credentials ICOI website listing and link to your practice at www.icoi.org Discounts on a wide range of textbooks and patient education materials Special member discounts to ICOI's solely sponsored meetings Certificates of membership    *Annual Membership Dues: Choose One(required) Category I Dental Practitioner - $350.00 Category II Full-time University Faculty/Military - $200.00 Category III Laboratory Technicians, Research or Industry Personnel $150 Category IV Pre-doctoral or Graduate Student - $100.00 As an added convenience, we accept Master Card, Visa and American Express payments. Card Type Choose One American Express MasterCard Visa Card Number Expiration Date Name on Card