{"id":24275,"date":"2025-10-09T11:43:08","date_gmt":"2025-10-09T15:43:08","guid":{"rendered":"https:\/\/www.michigandental.org\/?page_id=24275"},"modified":"2025-10-09T15:27:54","modified_gmt":"2025-10-09T19:27:54","slug":"waiver-of-dues-application","status":"publish","type":"page","link":"https:\/\/www.michigandental.org\/membership\/manage-membership\/waiver-of-dues-application\/","title":{"rendered":"Waiver of Dues Application"},"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>Waiver of Dues Application<\/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;.vc_custom_1760037830434{margin-bottom: 25px !important;}&#8221;]<span style=\"color: #b72028;\"><strong>*If you have retired, please complete the <a href=\"https:\/\/www.michigandental.org\/membership\/manage-membership\/retired-retired-life-membership-application\/\">Retired\/Retired Life Member Application<\/a>.\u00a0<\/strong><\/span><\/p>\n<p>Please complete this application with as much detail as possible that you would like to be taken into consideration of your dues reduction request. Email <a href=\"mailto:membership@michigandental.org\">membership@michigandental.org<\/a> with questions.[\/vc_column_text][\/vc_column][\/vc_row][vc_row css=&#8221;.vc_custom_1760023634759{background-color: #E6E6E6 !important;}&#8221;][vc_column css=&#8221;.vc_custom_1760024021468{margin-top: 15px !important;padding-top: 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 InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of 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class=\"gform_title\">Waiver of Dues Application<\/h2>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_124'  action='\/wp-json\/wp\/v2\/pages\/24275#gf_124' data-formid='124' novalidate><div class='gf_invisible ginput_recaptchav3' data-sitekey='6LcHpTIrAAAAAG71geNZWhEl5aFSv1vz-QYc-Xz3' data-tabindex='0'><input id=\"input_f7d6d8c371640c3e4ce6fabb83d163ea\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_f7d6d8c371640c3e4ce6fabb83d163ea\" 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_124' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_124_8\" class=\"gfield gfield--type-name gfield--input-type-name 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' >Name<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_124_8'>\n                            \n                            <span id='input_124_8_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_8.3' id='input_124_8_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_124_8_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_124_8_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_8.6' id='input_124_8_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_124_8_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_124_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_124_11'>ADA Number<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_124_11' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_124_53\" 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_124_53'>Local Society<\/label><div class='ginput_container ginput_container_select'><select name='input_53' id='input_124_53' class='large gfield_select'     aria-invalid=\"false\" ><option value='Select One' >Select One<\/option><option value='Central District' >Central District<\/option><option value='Cloverland District' >Cloverland District<\/option><option value='Copper Country District' >Copper Country District<\/option><option value='Detroit District' >Detroit District<\/option><option value='Genesee District' >Genesee District<\/option><option value='Jackson District' >Jackson District<\/option><option value='Kalamazoo Valley District' >Kalamazoo Valley District<\/option><option value='Lakeland Valley District' >Lakeland Valley District<\/option><option value='Livingston District' >Livingston District<\/option><option value='Macomb District' >Macomb District<\/option><option value='Manistee-Mason District' >Manistee-Mason District<\/option><option value='Muskegon District' >Muskegon District<\/option><option value='Ninth District' >Ninth District<\/option><option value='Northern Thumb District' >Northern Thumb District<\/option><option value='Oakland County District' >Oakland County District<\/option><option value='Resort District' >Resort District<\/option><option value='Saginaw Valley District' >Saginaw Valley District<\/option><option value='Sault Ste. Marie District' >Sault Ste. Marie District<\/option><option value='Southwestern District' >Southwestern District<\/option><option value='Superior District' >Superior District<\/option><option value='Thumb District' >Thumb District<\/option><option value='Vacationland District' >Vacationland District<\/option><option value='Washtenaw District' >Washtenaw District<\/option><option value='West Michigan District' >West Michigan District<\/option><\/select><\/div><\/div><fieldset id=\"field_124_16\" 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' >Home 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 has_country ginput_container_address gform-grid-row' id='input_124_16' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_124_16_1_container' >\n                                        <input type='text' name='input_16.1' id='input_124_16_1' value=''    aria-required='true'    \/>\n                                        <label for='input_124_16_1' id='input_124_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_124_16_2_container' >\n                                        <input type='text' name='input_16.2' id='input_124_16_2' value=''     aria-required='false'   \/>\n                                        <label for='input_124_16_2' id='input_124_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_124_16_3_container' >\n                                    <input type='text' name='input_16.3' id='input_124_16_3' value=''    aria-required='true'    \/>\n                                    <label for='input_124_16_3' id='input_124_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_124_16_4_container' >\n                                        <input type='text' name='input_16.4' id='input_124_16_4' value=''      aria-required='true'    \/>\n                                        <label for='input_124_16_4' id='input_124_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_124_16_5_container' >\n                                    <input type='text' name='input_16.5' id='input_124_16_5' value=''    aria-required='true'    \/>\n                                    <label for='input_124_16_5' id='input_124_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_124_16_6_container' >\n                                        <select name='input_16.6' id='input_124_16_6'   aria-required='true'    ><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_124_16_6' id='input_124_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><div id=\"field_124_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_124_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_124_45' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_124_44\" class=\"gfield gfield--type-phone gfield--input-type-phone 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_124_44'>Home\/Cell Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_44' id='input_124_44' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_124_48\" 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\"><\/h3><\/div><fieldset id=\"field_124_50\" 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' >I am requesting this waiver due to the following (select one):<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_124_50'>\n\t\t\t<div class='gchoice gchoice_124_50_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='Physical Disability (This option requires additional information beyond this form that the MDA will provide to you.)'  id='choice_124_50_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_124_50_0' id='label_124_50_0' class='gform-field-label gform-field-label--type-inline'>Physical Disability (This option requires additional information beyond this form that the MDA will provide to you.)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_124_50_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='Service to Country'  id='choice_124_50_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_124_50_1' id='label_124_50_1' class='gform-field-label gform-field-label--type-inline'>Service to Country<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_124_50_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='Financial Hardship'  id='choice_124_50_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_124_50_2' id='label_124_50_2' class='gform-field-label gform-field-label--type-inline'>Financial Hardship<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_124_50_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='Limited Hours\/Income'  id='choice_124_50_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_124_50_3' id='label_124_50_3' class='gform-field-label gform-field-label--type-inline'>Limited Hours\/Income<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_124_51\" 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\"  ><p>Please answer the following questions:<\/p><\/div><fieldset id=\"field_124_55\" 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' >1. Are you able to practice dentistry?<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_124_55'>\n\t\t\t<div class='gchoice gchoice_124_55_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Yes'  id='choice_124_55_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_124_55_0' id='label_124_55_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_124_55_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='No'  id='choice_124_55_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_124_55_1' id='label_124_55_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_124_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_124_19'>2. What is the number of patients seen per week?<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_124_19' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_124_20\" 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_124_20'>3. What are the number of hours practicing dentistry per week\/month?<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_20' id='input_124_20' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_124_57\" 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' >4. Are you earning an income from the practice of dentistry, the faculty of a dental school, or as a consultant?<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_124_57'>\n\t\t\t<div class='gchoice gchoice_124_57_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='Yes'  id='choice_124_57_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_124_57_0' id='label_124_57_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_124_57_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='No'  id='choice_124_57_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_124_57_1' id='label_124_57_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_124_58\" 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\"  >(If you do not earn an income, please complete the <a href=\"https:\/\/https:\/\/www.michigandental.org\/membership\/manage-membership\/retired-retired-life-membership-application\/\" target=\"_new\">Retired\/Retired Life Member Application<\/a>.  Please note that you can volunteer in the field of dentistry and be considered a retired member.)<\/div><div id=\"field_124_52\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_124_52'>Please use the space below to describe your current employment situation that you would like the MDA to take into consideration.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_52' id='input_124_52' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_124_34\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent 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' >Affidavit<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_34.1' id='input_124_34_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_124_34_1' >I understand that this reduced membership investment can be granted at either 50% or 100% dues relief if approved. I recognize that once it is processed, the Michigan Dental Association will notify me of the amount of relief granted and of the permanent or temporary status. I certify that the information provided in this statement is true and correct.<\/label><input type='hidden' name='input_34.2' value='I understand that this reduced membership investment can be granted at either 50% or 100% dues relief if approved. I recognize that once it is processed, the Michigan Dental Association will notify me of the amount of relief granted and of the permanent or temporary status. I certify that the information provided in this statement is true and correct.' class='gform_hidden' \/><input type='hidden' name='input_34.3' value='8' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_124_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_124_35'>\n                            \n                            <span id='input_124_35_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_35.3' id='input_124_35_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_124_35_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_124_35_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_35.6' id='input_124_35_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_124_35_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_124_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_124_36' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_124_36_1_container'>\n                                            <input type='number' maxlength='2' name='input_36[]' id='input_124_36_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_124_36_1' class='gform-field-label gform-field-label--type-sub 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