New Member Information
Dear Doctor,
Thank you for expressing an interest in joining the Inland Empire Perio Study Club.
This study club has been active since the 1960’s. It’s members are committed to improving their clinical skills in periodontics and implantology through hands-on and didactic activities.
The study club is successful and popular because each and every member is expected to actively contribute to the group. This high level of dedication requires significant financial and time commitment. Currently, dues are $2300/year.
Members are expected to be active participants at every meeting, procure items on the Supplies List, and occasionally make their office available for meeting activities.
The study club meets for five two-day (Friday/Saturday) sessions each year.
By talking to your sponsoring dentist, and by reviewing the reference materials on this website, you will get a better idea of what the study club is all about, and what is expected from each member.
To get temporary access to the password-protected Members Only areas, have your sponsoring dentist give your contact info to the study club president.
If you would like to become a member of the study club, and are willing to make the needed financial and time commitments required, then please complete and return the New Member Application to your sponsoring dentist.
Potential members might be further interviewed by current members, invited to attend one of the two-day sessions, placed on a waiting list, asked to pay a deposit, and/or voted into membership.
Sincerely,
Dr. Randy Otterholt, study club president;
Dr. Eric Ellingsen, study club secretary/treasurer
New Member Application
Name:_______________________________________________ Degree:_________________
Your email address:___________________________________ Spouse name:_______________
Office address:________________________________________
City:_____________________________ State:_______________ Zip:________________
Office phone:_______________ Home phone:_______________ Mobile phone:_______________
Dental School:______________________________________ Year of Graduation:______________
State Dental License number:____________________________
Which IEPSC member is sponsoring you?
Are you a member in good standing of the American Dental Association, and it’s component local dental society?
Have you had any disciplinary action taken against you by your state board of dentistry or board of pharmacy within the past five years?
Have you ever had your license to practice dentistry suspended or revoked?
Have you read and can you abide by all provisions of the Bylaws of the Inland Empire Perio Study Club?
Current and past study club memberships:
Dental organization memberships:
Professional liability insurance company:
Other comments you would like to add: