Southborough, Massachusetts 01745-1027
(800) 342-8747 • Fax: (508) 480-0002 www.massdental.org Date:
February 7, 2012
Meenakshy Yegneswaran, DMD
Marc Kaplan, CAE
Director of Membership
Waiver of Annual Membership Dues
Enclosed please find a Request For Waiver of Membership Dues form. The Society offers waivers as an outlet for dentists who want to be members but find themselves in situations where it is difficult to afford the annual dues. Waivers are granted for reasons of financial hardship or disability. Requests and information provided are held strictly confidential and are reviewed anonymously by the Society’s Waiver Review Committee. All identification
(including name, address, ADA number, and district) are removed from the request before the committee reviews the request.
Waiver applications must be legible and typewritten is preferred. Please return your completed form to me by email (email@example.com), mail (Two Willow St, Suite 200,
Southborough, MA 01745), or fax (508-480-0002). The form may also be completed online at www.massdental.org/waiverform
If you are applying for a financial hardship waiver please complete the additional questionnaire and return with your waiver form. You do not need to complete this questionnaire if applying for a disability waiver.
Thank you for your assistance and for taking the time to continue your membership in organized dentistry. Your membership helps maintain the strength of organized dentistry to speak for and protect the interests of dentists. If you have any questions please contact me at 800-342-8747 ext. 243 or by email at firstname.lastname@example.org.
Request for Waiver of Membership Dues
Department of Membership Information
211 East Chicago Avenue, Chicago, Illinois 60611
T 312.440.2699 F 312.440.2898 ADA.org
A full or partial waiver is available to a member in good standing whose circumstances have resulted in a significant financial hardship, including temporary or permanent disability, catastrophe, parental leave or medical illness.
1. All applicants should complete Section 1.
2. Applicants requesting a waiver due to Financial Hardship should complete Section 2, including the request for financial information.
3. Applicants requesting a waiver because of Financial Hardship due to Disability should have Section 3 completed by their physician.
4. Section 4 is to be completed by the constituent and component societies.
Please forward this completed form to your local society for their review and approval. They will send it to your state society for their review and the state society will forward it to the ADA.
To be completed by the member dentist
ADA ID Number
Meenakshy Yegneswaran, DMD
3 Greenwood Rd
I am requesting a waiver of dues from the American Dental Association and my constituent and component societies for the 2013
______________ membership year.
Financial Hardship Waiver (To be completed by the member dentist)
Please describe your financial situation and the reasons for your request for a financial dues waiver. Your local or state dental societies may request additional information in order to review your request. (This waiver may be requested by Humanitarian Practitioners.)
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