Life Member Bio Questionnaire

Please enter the text as you would like it to appear in the Newsletter. Your information will be edited and placed in paragraph format by the Newsletter Content Editor. Please include your email address below if you would like to review your information before it is published.

I can't emphasize enough how much it helps us if you can submit your information using this form instead of printing this page out and faxing your handwritten responses to us. This saves us a ton of work (since we would need to transcribe multiple bios per year), cuts down on errors (if we can't read the writing on the fax), etc. It is much easier on our Secretary, a volunteer, if this information is transmitted electronically. Also, please type this in using normal sentence case (not in all upper or lowercase).

Your name as you would like it to appear in the Newsletter:

When were you born (year)?

Where were you born?

(Country if not USA):

State:

City:

If served in the military:

Which branch?

Which years (start - finish)?

Other information about your military experience:

Undergraduate college/university:

Year graduated from college:

Undergraduate degree:

Dental school:

Year graduated from dental school:

Dental school degree: DDS DMD other:

Post-graduate dental training (Certificate) : School:

Year graduated from Certificate program:

Certificate (for combined certificates, use the "Other" box below):

Endodontics

Oral and Maxillofacial Surgery

Orthodontics and Dentofacial Orthopedics

Pediatric Dentistry

Periodontics

Prosthodontics

Other:

Other degrees or special training (e.g. Masters of Science in Oral Biology from UMDNJ in 1993):

What did you do after graduation from your last program (e.g. went to work for Dr. X in [location] until 1970, then opened my own practice in [location]; started teaching at _____ until 1970; etc.)?

Current Activities (e.g. actively practicing in [town]; retired and spending most of my time in Mexico; on faculty at [school]; serving as Chief of the Department of Dentistry at [hospital]; practicing part-time in [town]):

Current Professional Memberships:

ADA NJDA MCDS

Other Professional Memberships:

Past Professional Activities (e.g. Past-President of MCDS):

Where do you currently reside?

With whom do you currently reside (e.g. wife/husband and give name)?

Names of children:

Names and/or number of grandchildren:

Anything else you would like to add:

Your email address:

Click on the Submit You Bio button below to email your responses to Dr. Robert Silverstein (Newsletter layout editor).