---------------------------- Contact Information ----------------------------
*ADA Number
*First Name:
*Last Name:
*Office Address:
*Office City:
*Office State:
*Office Zip:
*Email Address:

-------------------------- 2013 Dues Itemization --------------------------
*American Dental Association:
*Mississippi Dental Association:
*Local District Dental Society:
MDA Political Action Contribution:

My contribution to MDPAC is reserved for political education
My contribution to MDPAC is unrestricted

ADA Political Action Contribution

ADPAC membership $50.00

Alliance to the MDA (Optional**)

**These are suggested amounts for voluntary contributions.  They do not affect your ADA, MDA or your District Dental Society membership status.  Please see the back of your dues statement for important Political Action Contribution information.

------------------------------ Payment Details ------------------------------

I will pay by: Check or Credit Card

If paying by check, please mail to:

Mississippi Dental Association
439B Katherine Drive
Flowood, MS  39232

If paying by credit card,
please enter the information below:

Visa Master Card American Express
Card Number:
Expiration Date:
Name as it appears on card:
3 digit security code:
(on back of card)

Questions or Comments:

Dues payments and contributions are not deductible as charitable contributions for federal income tax purposes to the extent that payments are not made to 501 (c) (3) organizations.  United States Taxpayers Please Note:  Under tax law, only that portion of an association member's dues not attributable to lobbying activities is deductible as an ordinary and necessary business expense.  For 2013, 9.0% of ADA dues, 14% of MDA dues and 0% of your local District Dental Society dues is allocable to lobbying activities and, therefore, nondeductible as a business expense.