Pay Your Dues Online

This form allows you to pay your LDA Membership Dues using your Visa or Mastercard. In the space provided, enter the dues amount found on your dues invoice you received in the mail.

If you did not receive an invoice, e-mail sharon@ladental.org, or call 1-800-388-6642 or (225) 926-1986.

*First Name:
*Last Name:
*Email:
*Address:
*City:
*State:
*ZIP:
*Phone Number:
FAX:
*ADA Number:


Please enter the full amount on your dues invoice:
   
OPTIONAL Foundation donation:
 
Please accept my gift of:
If "other", please enter amount:
Add $15 credit card convenience fee*
+ $15.00
Total Dues Being Paid the LDA:

P
lease enter your Credit Card information below:

Visa/Master Card Number:
Expiration Date:
Name as it appears on card:
3 digit security code on back of card:
Credit Card Type: Personal
Business

Questions or Comments:





*In accordance with a resolution of the LDA Board of Directors, beginning August 1, 2009, card users will be assessed a separate, non-refundable convenience fee of $15 at the time of each credit or debit card payment made to the Louisiana Dental Association (LDA). The non-refundable convenience fee will be included with your total payment amount on your credit card statement.

Automated Clearing House (ACH) payments, better known as automatic withdrawals for dues, from checking and savings accounts will continue to be accepted by the LDA via the ACH Network without a convenience fee. The LDA will also continue to accept check payments via mail or in person without a convenience fee.

The LDA accepts Visa and MasterCard.