Fellowship & Mastership

Academy of Laser Dentistry

Fellowship & Mastership

Application

Select an application type (must check one) Fellowship of the Academy of Laser Dentistry Mastership of the Academy of Laser Dentistry

Completed application forms must be submitted electronically to as an attachment. Your completed application including the letter of professional reference must be received by the Academy office by December 31st.

Personal Information

Last Name / First Name
/ Middle Name
/ Maiden Name
Date of birth
/ City/Country of birth
/ Country of citizenship / Gender
Female Male

Contact Information

Work / Work mailing address / Work phone
Work fax
Work e-mail
Home / Permanent mailing address / Home phone
Home fax
Permanent e-mail

EducationList institutions attended (above secondary school level), starting with the most recent.

Educational institution / Dates attended From – To (month/year) / Degree received
(or expected) / Date degree received
(or expected) / Fields of study
Major / Minor

Applicant’s Name: Date:

Please describe any honors, fellowships, career-related activities, publications, etc.

Occupational Experience

Year Began Practicing Dentistry
Type of Practice (e.g. General Practice, Pediatric, Orthodontics, Periodontics, etc.)
Sole Practitioner/ Group Practice
Website address

Personal Statement

Please write a narrative describing you as an individual. It should deal with your personal history; influences on your career choice; the educational, cultural, and other opportunities you have enjoyed; and the ways in which these experiences have affected your professional life goals. Please limit this statement to 500 words in English, and include this statement as part of your application.

Applicant’s Name: Date:

Letters of Reference

For your application to be complete, original letters of professional reference must be submitted by a professional dental colleague of equivalent degree stature who possesses first hand knowledge of your dental laser clinical expertise. Please provide contact information for the person you have asked to provide a letter of reference on your behalf. Download the form called Professional Reference Form and have the person providing the reference complete the form and e-mail it to . The reference form is available on the ALD website.
Reference’s full name / Reference’s title / Reference’s e-mail address / Reference’s phone number

IMPORTANT: All components of the application package must be received by the Academy office by December 31st. Late or incomplete applications will not be considered. Review of your application will begin when all components are received successfully.

Certification Confirmation

Provide the data below and attach copies of your certificate(s) to allow proper verification. Please make sure all data is provided. Applications will not be reviewed without this required information.

Level of Certification / Date(s) / Instructor / Device Tested On
Introductory Course
Standard Proficiency
Advanced Proficiency
Educator Course

Financial

Amount Due: $275 Initial Fellowship Application $450 Initial Mastership Application
Payment Type: Check No:
Please make check payable to the Academy of Laser Dentistry and mail it to the Academy of Laser Dentistry PO BOX 8667, Coral Springs, Florida 33075. / Credit Card
Yes, I will pay by credit card. Please send me an invoice for the appropriate application fee. Note to Applicant: Do not send credit card information in this form as email is not secure. We will send an invoice to you.

~ Laser Continuing Education Tracking Form follows on the next page ~

Laser Continuing Education Tracking Form

Use this form to provide all recognized continuing education hours spent in the discipline of laser dentistry for Fellowship (minimum 50 for initial application and 25 CE’s for ongoing renewal) or Mastership (minimum of 100 for initial application and 50 CE’s for ongoing renewal). Applicable CE includes all ADA, CERP or AGD-PACE laser lectures or courses. When using ALD Annual Conference Continuing Education Credits please make sure to provide the total CE hours obtained by your attendance. If providing international coursework be sure to provide enough information about the laser educational program to allow sufficient review to be counted towards the total required hours. You may scan any certifications and/or continuing education documents and attach them to your electronic application submission via email to . (Attach additional documents, if needed).

Date / Course Title / Instructor / Completion Code / Hours

I hereby confirm that the information provided in this application is truthful, complete, and up-to date.

Applicant Signature: / Date:

Academy of Laser DentistryFellowship/Mastership Application

Attention: Fellowship & Mastership ProgramPage 1 of 4

9900 W. Sample Road, Coral Springs, FL 33065 USA

Phone: 954-346-3776 or Toll Free 1-866-LASERS6 (527-3776); Fax: 954-757-2598

E-mail:; Web: