Membership: Application

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UTHSCSA Dental Alumni Association
Application Form

To join the UTHSCSA Dental Alumni Association, please do one of the following:

Download or Print the form below using the "print" option on your browser and mail the completed form to the address indicated with your membership payment and/or credit card information.

Downloads: forms.doc | forms.pdf

Print the form below and fax the completed form to (210) 567-6807 with your credit card information or request an invoice to be mailed to you.

OR Mail it to:

UTHSCSA Continuing Dental Education/Alumni Association

Office of the Dental Dean, Mail code: 7930

7703 Floyd Curl Dr.

San Antonio, TX 78229-3900

Name: ________________________________________________________

Class Year: _______________ Phone: _________________________

E-mail Address: _______________________________________________

Preferred Address: _______________________________________________

City/State/Zip: __________________________________________________

Is this address: ___ Home | ___ Work

Yes! Add me to the current membership roster!
___ $45 annual dues

___ $1000 lifetime membership

___ Bill me

___ Payment enclosed (payable to "UTHSCSA")

___ Credit card authorization below
Credit card charges may be made for contributions of $250 or more.
Circle one: ___ VISA | ___ MasterCard
Cardholder Name:___________________________________________________
Card Account#:_________________________ Expiration Date:_______________

Send me the information regarding the:
___ VISITATION Program | ___ Class Reunions | ___ Other Programs____________________

Return to Becoming a Member page