American Society of Master Dental Prosthologists, Inc.
146-21 13^th  Avenue
Whitestone, NY  11357
(718) 746-8355

Application Form
MASTER DENTAL TECHNOLOGIST HOME STUDY PROGRAM

CHAIRMAN

Vincent V. Alleluia, M.D.T., T.F.

PRESIDENT ELECT

Paul Federico, M.D.T.

VICE PRESIDENT

Paul Eliason, MDT, TF

EXECUTIVE DIRECTOR,

TREASURER & NORTHEAST

COORDINATOR

Sue Heppenheimer

WESTERN COORDINATOR

Jack Edwards, B.A., M.D.T., T.F.

FLORIDA & SOUTHEASTERN COORDINATOR

Robert Jackson, M.D.T., T.F.

COMMITTEE CHAIRPERSONS

EDUCATION

Vincent V. Alleluia, M.D.T., T.F.

MEMBERSHIP

Max Toth

BOARD OF EXAMINERS

Charles Cottone, M.D.T.

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Print Last Name

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Print First Name                                               Middle Initial

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Print Address

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City                                               State                                       Zip Code + four

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Home Phone w/area code                                         Work Phone w/area code

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Educational Profile: ______________________________________

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1)    Complete Application and attach a passport-size color photograph of yourself.

2)    Attach a $7,500.00 Check payable to DPDC (Dental Prosthologists
       Development, Corp.) to this form. 

3)    Mail check and completed form to above address.  You will be notified confirming your acceptance into
       the Home Study Program as soon as possible.