APPLICATION FOR MEMBERSHIP IN THE
ILLINOIS DENTAL LABORATORY ASSOCIATION

___________________________________________________________________________
(print or type name of laboratory)
hereby makes application to the above 
named Association; on this ______ day of _____________20 ____; and in doing 
so, its Owner(s) agree to abide by the Association's Constitution and 
By-Laws and its Code of Ethics.

Owner(s) Name(s) ___________________________________________________________
Title__________________________
(print or type name, CDT if applicable, title)
_______________________________________________________________
Title__________________________

Laboratory Address__________________________________Email____________________
City ___________________________State______
Zip___________Phone_________________Fax___________________
How long in business? __________ 
Number of owners and full-time technicians. ______
Do you own building or rent? _____________ 
Is lab in a commercial location or home?______________________
Lab Specialties: Dentures ____ Partial____C&B____Ceramics____ Ortho____ 
Implant____ Mill ____ Cosmetic ____

Federal Tax Identification Number: ______________________________
PLEASE SUBMIT THE NAMES OF TWO IDLA MEMBERS AS REFERENCE

Reference:
_______________________________________________________________________________
_______________________________________________________________________________

Please read the following and sign:

CONSTITUTION AND BY-LAWS ­ ARTICLE III ­ MEMBERSHIP
Section 1:  Active Membership
Active and incapacitated Memberships­shall be those ethical commercial
dental laboratories located in the State of Illinois, operated by persons 
of good ethical reputation under the supervision of dental technicians, 
as private ownerships, partnerships or corporations, and whose services 
are exclusively available to members of the ethical dental profession 
and/or other ethical dental laboratories.

Are you in compliance with local zoning laws and municipal 
ordinances? ____Yes____No.  
If no, have you received a variance (permit to operate not in compliance 
with local zoning laws, etc.)?  ____Yes____No.


I have read the above and certify that our laboratory falls within the 
interpretation of the Constitution and ByLaws, Article III Section I.   
Owner(s) signature, home address and phone number must appear.

__________________________________      ______________________________________    
 (signature)                            	(home address and phone number)

__________________________________      ______________________________________    
(signature)                             	(home address and phone number)

Return to:  Illinois Dental Laboratory Association
            P.O. Box 9739
            Naperville, IL  60567-9739
			
Please Bill:     
	 Annually
	 Semi-Annual
	 Quarterly
	
IMPORTANT:  A $100 deposit is required on  submission of this membership 
application.  The deposit will be applied to annual dues after application 
approval. The deposit will be returned in the event that the application 
is not approved.