---------------------------- Your Information ----------------------------

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

A confirmation will be sent to this email address.

------------------------- 2014 Dues Itemization -------------------------

*American Dental Association:
*Mississippi Dental Association:
*Local District Dental Society:
MDA Political Action Contribution:

Other Amount $
ADA Political Action Contribution

Other Amount: $

MDA Foundation (Optional**)

Other Amount: $
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.

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

Total amount of fees due to the MDA will appear
on the following confirmation screen.

I will pay by: Check or Credit Card

If paying by check, please mail to:

Mississippi Dental Association
439 B Katherine Drive
Flowood MS 39232-9781

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

Card Type: 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 2014, 7.5% of ADA dues, 15% of MDA dues and 0% of your local District Dental Society dues is allocable to lobbying activities and, therefore, nondeductible as a business expense.

Your financial support of the MDA Foundation, a 501 (C)(3) organization is tax deductible to the extent permitted by law.