{"id":23116,"date":"2025-08-05T11:25:38","date_gmt":"2025-08-05T15:25:38","guid":{"rendered":"https:\/\/www.michigandental.org\/?page_id=23116"},"modified":"2025-09-04T08:02:43","modified_gmt":"2025-09-04T12:02:43","slug":"member-application-form","status":"publish","type":"page","link":"https:\/\/www.michigandental.org\/membership\/join-the-mda\/member-application-form\/","title":{"rendered":"Member Application Form"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row full_width=&#8221;stretch_row&#8221; css=&#8221;.vc_custom_1698696973333{margin-top: -40px !important;padding-top: 0px !important;padding-bottom: 20px !important;background-color: #009ba7 !important;}&#8221; el_class=&#8221;white-text&#8221;][vc_column][vc_column_text css=&#8221;&#8221;]<\/p>\n<h1>Membership Application Form<\/h1>\n<p><nav  aria-label=\"breadcrumb\"><ol class=\"breadcrumb\" itemscope itemtype=\"https:\/\/schema.org\/BreadcrumbList\"><li class=\"breadcrumb-item active\" aria-current=\"page\" itemprop=\"itemListElement\" itemscope itemtype=\"https:\/\/schema.org\/ListItem\"><span itemprop=\"name\">Home<\/span><meta itemprop=\"position\" content=\"1\"><\/li><\/ol><\/nav>[\/vc_column_text][\/vc_column][\/vc_row][vc_row][vc_column][vc_column_text css=&#8221;&#8221;]Complete the Membership Application Form below to become a part of the Michigan Dental Association, American Dental Association, and your local dental society. Joining isn\u2019t just about membership \u2014 it\u2019s also about surrounding yourself with the people, programs, and perks that will help you grow within the dental profession and help you do what you do best: delivering top-notch patient care.[\/vc_column_text][\/vc_column][\/vc_row][vc_row css=&#8221;.vc_custom_1754322242784{background-color: #D7DBE0 !important;}&#8221;][vc_column css=&#8221;.vc_custom_1754322631804{padding-top: 5px !important;padding-bottom: 5px !important;}&#8221;]<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_unknown gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_117' style='display:none'><div id='gf_117' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Membership Application<\/h2>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_117'  action='\/wp-json\/wp\/v2\/pages\/23116#gf_117' data-formid='117' novalidate><div class='gf_invisible ginput_recaptchav3' data-sitekey='6LcHpTIrAAAAAG71geNZWhEl5aFSv1vz-QYc-Xz3' data-tabindex='0'><input id=\"input_94941f2efe7076aa4a4278e04a9b70d6\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_94941f2efe7076aa4a4278e04a9b70d6\" value=\"\"\/><\/div> \r\n <input type='hidden' class='gforms-pum' value='{\"closepopup\":false,\"closedelay\":0,\"openpopup\":false,\"openpopup_id\":0}' \/>\n                        <div class='gform-body gform_body'><div id='gform_fields_117' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_117_8\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_117_8'>\n                            \n                            <span id='input_117_8_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_8.3' id='input_117_8_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_117_8_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            <span id='input_117_8_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_8.4' id='input_117_8_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_117_8_4' class='gform-field-label gform-field-label--type-sub '>Middle Initial<\/label>\n                                                <\/span>\n                            <span id='input_117_8_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_8.6' id='input_117_8_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_117_8_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_117_9\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_117_9'>Credentials<\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_117_9' type='text' value='' class='large'  aria-describedby=\"gfield_description_117_9\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_117_9'>(DDS, DMD, MPH, MS, etc.)<\/div><\/div><div id=\"field_117_44\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_117_44'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_44' id='input_117_44' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_117_45\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_117_45'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_45' id='input_117_45' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_117_11\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_117_11'>ADA Number (if known)<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_117_11' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_117_12\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_117_12'>Michigan License Number<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_117_12' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_117_13\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_117_13'>Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_117_13' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_117_14\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div id='input_117_14' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_117_14_1_container'>\n                                            <input type='number' maxlength='2' name='input_14[]' id='input_117_14_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_117_14_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_117_14_2_container'>\n                                            <input type='number' maxlength='2' name='input_14[]' id='input_117_14_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_117_14_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_117_14_3_container'>\n                                            <input type='number' maxlength='4' name='input_14[]' id='input_117_14_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2026' step='1'\/>\n                                            <label for='input_117_14_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><fieldset id=\"field_117_15\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Billing Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_117_15' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_117_15_1_container' >\n                                        <input type='text' name='input_15.1' id='input_117_15_1' value=''    aria-required='true'    \/>\n                                        <label for='input_117_15_1' id='input_117_15_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_117_15_2_container' >\n                                        <input type='text' name='input_15.2' id='input_117_15_2' value=''     aria-required='false'   \/>\n                                        <label for='input_117_15_2' id='input_117_15_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_117_15_3_container' >\n                                    <input type='text' name='input_15.3' id='input_117_15_3' value=''    aria-required='true'    \/>\n                                    <label for='input_117_15_3' id='input_117_15_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_117_15_4_container' >\n                                        <select name='input_15.4' id='input_117_15_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_117_15_4' id='input_117_15_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_117_15_5_container' >\n                                    <input type='text' name='input_15.5' id='input_117_15_5' value=''    aria-required='true'    \/>\n                                    <label for='input_117_15_5' id='input_117_15_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_15.6' id='input_117_15_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_117_47\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Primary Office Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    <div id='input_117_47_copy_values_option_container' class='copy_values_option_container' >\n                                        <input type='checkbox' id='input_117_47_copy_values_activated' class='copy_values_activated' value='1' data-source_field_id='15' name='input_47_copy_values_activated'  \/>\n                                        <label for='input_117_47_copy_values_activated' id='input_117_47_copy_values_option_label' class='copy_values_option_label inline gform-field-label gform-field-label--type-inline'>Same as billing address<\/label>\n                                    <\/div>\n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_117_47' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_117_47_1_container' >\n                                        <input type='text' name='input_47.1' id='input_117_47_1' value=''    aria-required='true'    \/>\n                                        <label for='input_117_47_1' id='input_117_47_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_117_47_2_container' >\n                                        <input type='text' name='input_47.2' id='input_117_47_2' value=''     aria-required='false'   \/>\n                                        <label for='input_117_47_2' id='input_117_47_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_117_47_3_container' >\n                                    <input type='text' name='input_47.3' id='input_117_47_3' value=''    aria-required='true'    \/>\n                                    <label for='input_117_47_3' id='input_117_47_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_117_47_4_container' >\n                                        <select name='input_47.4' id='input_117_47_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_117_47_4' id='input_117_47_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_117_47_5_container' >\n                                    <input type='text' name='input_47.5' id='input_117_47_5' value=''    aria-required='true'    \/>\n                                    <label for='input_117_47_5' id='input_117_47_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_47.6' id='input_117_47_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_117_16\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Home Address<\/legend>    <div id='input_117_16_copy_values_option_container' class='copy_values_option_container' >\n                                        <input type='checkbox' id='input_117_16_copy_values_activated' class='copy_values_activated' value='1' data-source_field_id='15' name='input_16_copy_values_activated'  \/>\n                                        <label for='input_117_16_copy_values_activated' id='input_117_16_copy_values_option_label' class='copy_values_option_label inline gform-field-label gform-field-label--type-inline'>Same as billing address<\/label>\n                                    <\/div>\n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_117_16' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_117_16_1_container' >\n                                        <input type='text' name='input_16.1' id='input_117_16_1' value=''    aria-required='false'    \/>\n                                        <label for='input_117_16_1' id='input_117_16_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_117_16_2_container' >\n                                        <input type='text' name='input_16.2' id='input_117_16_2' value=''     aria-required='false'   \/>\n                                        <label for='input_117_16_2' id='input_117_16_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_117_16_3_container' >\n                                    <input type='text' name='input_16.3' id='input_117_16_3' value=''    aria-required='false'    \/>\n                                    <label for='input_117_16_3' id='input_117_16_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_117_16_4_container' >\n                                        <input type='text' name='input_16.4' id='input_117_16_4' value=''      aria-required='false'    \/>\n                                        <label for='input_117_16_4' id='input_117_16_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_117_16_5_container' >\n                                    <input type='text' name='input_16.5' id='input_117_16_5' value=''    aria-required='false'    \/>\n                                    <label for='input_117_16_5' id='input_117_16_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_117_16_6_container' >\n                                        <select name='input_16.6' id='input_117_16_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_117_16_6' id='input_117_16_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_117_17\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Preferred Mailing Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_117_17'>\n\t\t\t<div class='gchoice gchoice_117_17_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Home'  id='choice_117_17_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_117_17_0' id='label_117_17_0' class='gform-field-label gform-field-label--type-inline'>Home<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_117_17_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Work'  id='choice_117_17_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_117_17_1' id='label_117_17_1' class='gform-field-label gform-field-label--type-inline'>Work<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_117_18\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_117_18'>Dental School<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_117_18' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_117_19\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_117_19'>Graduation Year<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_117_19' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_117_20\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_117_20'>Advanced Education Program<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_117_20' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_117_21\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_117_21'>Year of Graduation<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_117_21' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_117_22\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_117_22'>Specialty<\/label><div class='ginput_container ginput_container_select'><select name='input_22' id='input_117_22' class='large gfield_select'     aria-invalid=\"false\" ><option value='Select One' >Select One<\/option><option value='Anesthesiology' >Anesthesiology<\/option><option value='Endodontics' >Endodontics<\/option><option value='Oral and Maxillofacial Pathology' >Oral and Maxillofacial Pathology<\/option><option value='Oral and Maxillofacial Radiology' >Oral and Maxillofacial Radiology<\/option><option value='Oral and Maxillofacial Surgery' >Oral and Maxillofacial Surgery<\/option><option value='Oral Medicine' >Oral Medicine<\/option><option value='Orofacial Pain' >Orofacial Pain<\/option><option value='Orthodontics and Dentofacial Orthopedics' >Orthodontics and Dentofacial Orthopedics<\/option><option value='Pediatric Dentistry' >Pediatric Dentistry<\/option><option value='Periodontics' >Periodontics<\/option><option value='Prosthodontics' >Prosthodontics<\/option><option value='Public Health' >Public Health<\/option><\/select><\/div><\/div><fieldset id=\"field_117_23\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you ever been denied a dental license?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_117_23'>\n\t\t\t<div class='gchoice gchoice_117_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Yes'  id='choice_117_23_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_117_23_0' id='label_117_23_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_117_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='No'  id='choice_117_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_117_23_1' id='label_117_23_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_117_24\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_117_24'>If Yes, in which state?<\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_117_24' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_117_25\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_117_25'>If Yes, why?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_25' id='input_117_25' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_117_26\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you ever had your license suspended or revoked?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_117_26'>\n\t\t\t<div class='gchoice gchoice_117_26_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='Yes'  id='choice_117_26_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_117_26_0' id='label_117_26_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_117_26_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='No'  id='choice_117_26_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_117_26_1' id='label_117_26_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_117_27\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_117_27'>If Yes, in which state?<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_117_27' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_117_28\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_117_28'>If Yes, why?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_28' id='input_117_28' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_117_29\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you ever been censored, suspended, or expelled by a dentally related organization (i.e., dental society)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_117_29'>\n\t\t\t<div class='gchoice gchoice_117_29_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Yes'  id='choice_117_29_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_117_29_0' id='label_117_29_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_117_29_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='No'  id='choice_117_29_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_117_29_1' id='label_117_29_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_117_30\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_117_30'>If Yes, in which state?<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_117_30' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_117_31\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_117_31'>If Yes, why?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_31' id='input_117_31' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_117_32\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you ever been convicted of a felony or criminal offense, including driving under the influence of alcohol or drugs, but excluding minor traffic violations and parking tickets?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_117_32'>\n\t\t\t<div class='gchoice gchoice_117_32_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='Yes'  id='choice_117_32_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_117_32\"   \/>\n\t\t\t\t\t<label for='choice_117_32_0' id='label_117_32_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_117_32_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='No'  id='choice_117_32_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_117_32_1' id='label_117_32_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_117_32'>(A conviction record will not automatically bar you from membership. Each application will be individually considered on its merits.) <\/div><\/fieldset><div id=\"field_117_33\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_117_33'>If Yes, please describe (include dates, offenses and penalties):<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_33' id='input_117_33' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_117_34\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<\/legend><div class='ginput_container ginput_container_consent'><input name='input_34.1' id='input_117_34_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_117_34_1' >I herby apply for tripartite membership in the American Dental Association and resolve to abide by the <em>Bylaws<\/em> and <em>Principles of Ethics and Code of Professional Conduct<\/em> if accepted into membership. By typing my name below, I consent to use electronic means to sign this document and agree that my electronic signature is the legal equivalent of my handwritten signature. I further agree that my signature, whether electronic or written, is valid and binding for all purposes related to this document.<\/label><input type='hidden' name='input_34.2' value='I herby apply for tripartite membership in the American Dental Association and resolve to abide by the &lt;em&gt;Bylaws&lt;\/em&gt; and &lt;em&gt;Principles of Ethics and Code of Professional Conduct&lt;\/em&gt; if accepted into membership. By typing my name below, I consent to use electronic means to sign this document and agree that my electronic signature is the legal equivalent of my handwritten signature. I further agree that my signature, whether electronic or written, is valid and binding for all purposes related to this document.' class='gform_hidden' \/><input type='hidden' name='input_34.3' value='1' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_117_35\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_117_35'>\n                            \n                            <span id='input_117_35_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_35.3' id='input_117_35_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_117_35_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_117_35_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_35.6' id='input_117_35_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_117_35_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_117_36\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div id='input_117_36' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_117_36_1_container'>\n                                            <input type='number' maxlength='2' name='input_36[]' id='input_117_36_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_117_36_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_117_36_2_container'>\n                                            <input type='number' maxlength='2' name='input_36[]' id='input_117_36_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_117_36_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_117_36_3_container'>\n                                            <input type='number' maxlength='4' name='input_36[]' id='input_117_36_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2026' step='1'\/>\n                                            <label for='input_117_36_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div id=\"field_117_37\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Let&#039;s Calculate Your Dues<\/h3><\/div><div id=\"field_117_46\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >The local society is based on your practice address county. If you do not have a practice address, use your home address or the area you plan to practice. <a href=\"https:\/\/www.michigandental.org\/wp-content\/uploads\/2025\/08\/Local-Dental-Societies-by-County.pdf\" target=\"_new\">Find your local society by county.<\/a><\/div><fieldset id=\"field_117_43\" class=\"gfield gfield--type-product gfield--type-choice gfield--input-type-radio gfield--width-half gfield_price gfield_price_117_43 gfield_product_117_43 gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Local Society<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_117_43'>\n\t\t\t<div class='gchoice gchoice_117_43_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Central District|110'  id='choice_117_43_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_117_43_0' id='label_117_43_0' class='gform-field-label gform-field-label--type-inline'>Central District<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_117_43_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Cloverland District|40'  id='choice_117_43_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_117_43_1' id='label_117_43_1' class='gform-field-label gform-field-label--type-inline'>Cloverland District<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_117_43_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Copper Country District|50'  id='choice_117_43_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_117_43_2' id='label_117_43_2' class='gform-field-label gform-field-label--type-inline'>Copper Country District<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_117_43_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Detroit District|230'  id='choice_117_43_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_117_43_3' id='label_117_43_3' class='gform-field-label gform-field-label--type-inline'>Detroit District<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_117_43_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Genesee District|200'  id='choice_117_43_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_117_43_4' id='label_117_43_4' class='gform-field-label gform-field-label--type-inline'>Genesee District<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_117_43_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Jackson District|200'  id='choice_117_43_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_117_43_5' id='label_117_43_5' class='gform-field-label gform-field-label--type-inline'>Jackson District<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_117_43_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Kalamazoo Valley District|200'  id='choice_117_43_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_117_43_6' id='label_117_43_6' class='gform-field-label gform-field-label--type-inline'>Kalamazoo Valley District<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_117_43_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Lakeland Valley District|120'  id='choice_117_43_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_117_43_7' id='label_117_43_7' class='gform-field-label gform-field-label--type-inline'>Lakeland Valley District<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_117_43_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Livingston District|150'  id='choice_117_43_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_117_43_8' id='label_117_43_8' class='gform-field-label gform-field-label--type-inline'>Livingston District<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_117_43_9'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Macomb District|215'  id='choice_117_43_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_117_43_9' id='label_117_43_9' class='gform-field-label gform-field-label--type-inline'>Macomb District<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_117_43_10'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Manistee-Mason District|75'  id='choice_117_43_10' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_117_43_10' id='label_117_43_10' class='gform-field-label gform-field-label--type-inline'>Manistee-Mason District<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_117_43_11'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Muskegon District|235'  id='choice_117_43_11' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_117_43_11' id='label_117_43_11' class='gform-field-label gform-field-label--type-inline'>Muskegon District<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_117_43_12'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Ninth District|240'  id='choice_117_43_12' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_117_43_12' id='label_117_43_12' class='gform-field-label gform-field-label--type-inline'>Ninth District<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_117_43_13'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Northern Thumb District|100'  id='choice_117_43_13' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_117_43_13' id='label_117_43_13' class='gform-field-label gform-field-label--type-inline'>Northern Thumb District<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_117_43_14'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Oakland County District|280'  id='choice_117_43_14' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_117_43_14' id='label_117_43_14' class='gform-field-label gform-field-label--type-inline'>Oakland County District<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_117_43_15'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Resort District|45'  id='choice_117_43_15' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_117_43_15' id='label_117_43_15' class='gform-field-label gform-field-label--type-inline'>Resort District<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_117_43_16'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Saginaw Valley District|110'  id='choice_117_43_16' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_117_43_16' id='label_117_43_16' class='gform-field-label gform-field-label--type-inline'>Saginaw Valley District<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_117_43_17'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Sault Ste. Marie District|0'  id='choice_117_43_17' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_117_43_17' id='label_117_43_17' class='gform-field-label gform-field-label--type-inline'>Sault Ste. Marie District<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_117_43_18'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Southwestern District|80'  id='choice_117_43_18' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_117_43_18' id='label_117_43_18' class='gform-field-label gform-field-label--type-inline'>Southwestern District<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_117_43_19'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Superior District|150'  id='choice_117_43_19' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_117_43_19' id='label_117_43_19' class='gform-field-label gform-field-label--type-inline'>Superior District<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_117_43_20'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Thumb District|100'  id='choice_117_43_20' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_117_43_20' id='label_117_43_20' class='gform-field-label gform-field-label--type-inline'>Thumb District<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_117_43_21'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Vacationland District|75'  id='choice_117_43_21' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_117_43_21' id='label_117_43_21' class='gform-field-label gform-field-label--type-inline'>Vacationland District<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_117_43_22'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Washtenaw District|225'  id='choice_117_43_22' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_117_43_22' id='label_117_43_22' class='gform-field-label gform-field-label--type-inline'>Washtenaw District<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_117_43_23'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='West Michigan District|200'  id='choice_117_43_23' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_117_43_23' id='label_117_43_23' class='gform-field-label gform-field-label--type-inline'>West Michigan District<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_117_42\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><img decoding=\"async\" class=\"aligncenter lazyload\" data-src=\"https:\/\/www.michigandental.org\/wp-content\/uploads\/2025\/05\/MDA-Component-Map_Regions-scaled.png\" alt=\"Dr. Cheri Newman\" width=\"400\" height=\"580\" src=\"data:image\/svg+xml;base64,PHN2ZyB3aWR0aD0iMSIgaGVpZ2h0PSIxIiB4bWxucz0iaHR0cDovL3d3dy53My5vcmcvMjAwMC9zdmciPjwvc3ZnPg==\" style=\"--smush-placeholder-width: 400px; --smush-placeholder-aspect-ratio: 400\/580;\" \/><\/div><div id=\"field_117_7\" class=\"gfield gfield--type-product gfield--input-type-select gfield--width-full gfield_price gfield_price_117_7 gfield_product_117_7 gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_117_7'>What represents your primary occupation?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_7' id='input_117_7' class='large gfield_select'  aria-describedby=\"gfield_description_117_7\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='|0' ><\/option><option value='Practicing Dentist|1445' >Practicing Dentist<\/option><option value='Public Health Dentist|1150' >Public Health Dentist<\/option><option value='Full-Time Faculty|430' >Full-Time Faculty<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_117_7'>(Pick the closest match.)  <\/div><\/div><div id=\"field_117_38\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><strong>If none of these apply or you have a question, <a href=\"mailto:membership@michigandental.org\" target=\"_new\">click here<\/a>.<\/strong><\/div><div id=\"field_117_40\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Payment Information<\/h3><\/div><fieldset id=\"field_117_6\" class=\"gfield gfield--type-creditcard gfield--input-type-creditcard gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Credit Card<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container_creditcard gform-grid-row' id='input_117_6'><span class='ginput_full gform-grid-col' id='input_117_6_1_container' >\n                                    <div class='gform_card_icon_container'><div class='gform_card_icon gform_card_icon_amex' >American Express<\/div><div class='gform_card_icon gform_card_icon_discover' >Discover<\/div><div class='gform_card_icon gform_card_icon_mastercard' 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<legend class='gform-field-label gform-field-label--type-sub '>Expiration Date<\/legend>\n                                                <span class='ginput_card_expiration_container ginput_card_field gform-grid-row'>\n                                                   <span class='ginput_card_expiration_month_container gform-grid-col'>\n                                                       <label for='input_117_6_2_month' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                                       <select  id='input_117_6_2_month'   class='ginput_card_expiration ginput_card_expiration_month' aria-required='true'  >\n                                                           <option value=''>Month<\/option><option value='1' >01<\/option><option value='2' >02<\/option><option value='3' >03<\/option><option value='4' >04<\/option><option value='5' >05<\/option><option value='6' >06<\/option><option value='7' 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