OERF Membership Form 2024

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For new members or members that would like to be part of the Sustained Giving Program, please fill out the following information.

Email *

First Name *

Middle Name *

Last Name *

Billing Address *

City *

State *

Billing Zip Code (must match credit card listed below using to pay dues) *

Telephone Number *

Orthodontic School *

Year of Graduation *

Practicing Orthodontics

Full Time

Part Time

Clear selection

Teaching Orthodontics

Full Time

Part Time

Not at this time

Clear selection

I would like to pay my dues through: *

A one time charge of $400.00 (OERF) Annual dues ( Annual meeting Award dinner not included)

Gold Sustained giving program $1200-2999 per year ( Example: $100 per month x 12 mo or divided by 12 if a different amount - which includes annual meeting, membership dues and Merit Award Banquet). The program starts in January of 2024

Platinum Sustained giving program $3000-5999 per year (Example: $250 per month x 12 mo or divided by 12 if a different amount- which includes annual meeting, membership dues, Merit Award Banquet and donation). The programs starts in January 2024.

Sotiropoulos Sustained giving program $6000 or more per year (Example: $500 per month x 12 mo or divided by 12 if a different amount- which includes annual meeting, membership dues, Merit Award banquet, Custom pin recognizing your contribution to OERF/orthodontics and donation.). The program starts in January of 2024.

Member of the faculity

Credit Card Number for Dues *

Expiration of Credit Card *

CVV Code *

Send me a copy of my responses.

Submit

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