Association Membership Application
Name:
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Number:
*
Please enter a valid phone number.
Alternate Number:
Please enter a valid phone number.
Email:
*
example@example.com
Date of Birth:
*
-
Month
-
Day
Year
Date
Association Benefit Level Desired (Benefits Include All Family Members, You Will Not Be Charged Today):
*
Silver - $15.00
Gold - $20.00
Platinum - $30.00
Additional Benefit of Interest:
*
Health
Dental
Vision
Tele-Medicine
Tele-Dentistry
Shopping/Dining Discounts
Travel Discounts (Air, Hotel, Car & More)
Theme Park Discounts
Identity Theft Protection
National Association for Medical and Dental (NAFMD) collects visitors' voluntarily provided personal data through the "Contact" page of this website. This includes all of the displayed information fields. (Visitor name, postal address, E-mail address, telephone number, etc.) Personal information is transmitted using our SSL secure server with 2048-bit encryption for added protection. NAFMD is not responsible for technical problems that are not in direct connection with our server or contacting processes that may occur resulting in others viewing your information. The collected information may be used to contact you via phone calls, texts (landline and cell), fax, e-mail, or regular mail to provide you with information that we believe may be of interest to you. Collected information will never be sold or transferred to other parties outside of NAFMD without your permission. All non-personal information (questions, comments, ideas, suggestions and other feedback) is regarded as non-confidential. By sending a message to NAFMD, visitors acknowledge and understand that all non-personal information is considered non-confidential. NAFMD is free to disseminate by any means and use for any purpose this non-confidential information without restrictions and without any obligation to the visitor.“By pressing the Send Message button, I expressly consent to be contacted at the phone number I provided (including by phone call, texts (landline and cell), or fax), regarding my message as well as information that NAFMD and Healthcare National Marketing, Inc. believes might be of interest to me, using an automatic telephone dialing system and/or artificial or pre-recorded voice, regardless of my status on any state or federal do not call list. I understand that I am not required to provide this consent to make a purchase from NAFMD and Healthcare National Marketing, Inc. or to use any of its services, including any online services.“Please see our full privacy policy for more information. If a visitor does not wish to be contacted by NAFMD or have questions regarding the website and/or NAFMD's privacy policy, contact us at(844)689-2758.
*
I agree to the terms & conditions
Date:
*
-
Month
-
Day
Year
Date
By Typing Your Name, You Are Agreeing To The Terms Above:
*
First Name
Last Name
Submit
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