Office Use Only
Amount & Check #________
Application for Fellowship
Name:
Home Address:
City:
State:
Office Address:
City:
State:
Preferred Mail to: Home E-mail:
Date: ___________________
Zip:
Zip:
Home Telephone:
Work Telephone:
Fax Number:
Professional Education (DDS, DMD, or an internationally equivalent degree required)
School
Dates Attended
Degree
1.
2.
3.
4.
References/Sponsors
Two recommendation letters are required. One must be a current fellow within the area being sought and
one must be a professional colleague.
List below the full name, position, address and telephone number of two individuals providing references.
1.
Name:
Position:
Address:
Phone:
2.
Name:
Position:
Address:
Phone:
Checklist
Enclosed application/examination fee of $500 (US Funds only) made to Special Care
Dentistry Association
Membership in SCDA for at least three years
Attend at least three SCDA Annual Meetings within the last five years
Complete a minimum of thirty hours of Special Care CE with SCDA within the last five years
Attach current Curriculum Vitae that documents teaching, publications, leadership, research, patient
care and other scholarly activities related to the Fellowship
Two reference/sponsor letters
Agreement to Conditions of Application:
I understand that as an applicant for Fellowship, I have the burden of producing adequate information for
proper evaluation of my application and that failure to produce this information will prevent my
application from being evaluated and acted upon.
Information given in or attached to this application is accurate to the best of my knowledge and belief. I
fully understand and agree as a condition to making this application that any significant
misrepresentation, misstatement in, or omission from this application, whether intentional or not, shall, of
itself alone, constitute cause for automatic and immediate rejection of this application.
To the fullest extent permitted by the law, I extend absolute immunity to and release the SCDA , its
authorized representatives, and any third party from any and all civil liability arising from any acts,
communications, reports, recommendations, or disclosure, including otherwise privileged or confidential
information, involving me, performed, made or received in good faith, by the SCDA and Council on
Fellowship and its authorized representatives, to, by or from any third party anywhere, at any time,
concerning activities relating to but not limited to: inquiries relating to character, mental or emotional
stability, physical condition, ethics, behavior or any other matter that might directly or indirectly relate to
my professional competence and/or the information set forth in this application.
A check for $500 per examination being sought must accompany this application. (Please remit in U.S.
dollars) Make check payable to: Special Care Dentistry Association.
Applicant Signature_______________________________________Date:_______________________
Mail to: SCDA Fellowship, 330 N. Wabash Ave. Suite 2000. Chicago, IL 60611