Membership Status Change Request

The Academy of General Dentistry (AGD) recognizes that members’ circumstances change throughout their careers. To assist members through these transitions, the AGD offers various membership status options to current members in good standing. In the event your situation does not fall under any of these categories, you may submit a special request for consideration by the Membership Council to

If you wish to apply for a status change, please complete this application and provide a one-page letter explaining your situation as supporting documentation. This information will be provided to the Membership Council for their review.

Please select the option that best represents your circumstances.
Leave of Absence
Total Disability
Retired Membership
I hereby attest that I am eligible for the above dues waiver request, and that my license to practice dentistry has not been revoked or suspended.
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