CADP Membership Application Select Your Category of Membership(Required) Plan Member (Knox-Keene Licensed Plan) Associate Member (Non-Knox-Keene Licensed Plan or Organization) Individual Member (Individual Person) Full Members (Complete sections 1-4) Associate Member (Complete sections 1 and 2) Individual Member (Complete section 1 only) Section 1 - Contact InfoName(Required) First Last Suffix Company Name(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone(Required)Email(Required) Section 2 - Names and Titles of Key Company Executives(for plan and associates only)President / CEO of your company Chief Operating Officer Dental Director Chief Financial Officer Senior Marketing Director Section 3 - Dental Plan Information OnlyParent Company Name Knox-Keen License # Other States where Licensed Operate Number of Subscribers Number of Members Section 4 - Delegate: Indicate person who will have authority from your company to vote on CADP MattersName First Last Email Phone Associate Dues: $1,581 annually Individual Dues: $220 annually Plans: Based on weighted enrollment multiplied by per enrollee rate. Email chapinr@cadp.org for an estimate. After submitting this form, Rene Chapin with CADP Membership will be contacting you for payment information. Δ
