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First Name
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Last Name
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Address
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State
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Email
Cell Phone
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Cell Phone 2
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Component
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Acadiana District Dental Association
Bayou District Dental Association
Central Louisiana Dental Association
Greater Baton Rouge Dental Association
New Orleans Dental Association
Northeast Louisiana Dental Association
Northlake District Dental Association
Northwest Louisiana Dental Association
Southwest District Dental Association
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I Agree
I consent to receive automatically-dialed calls/messages from the Louisiana Dental Association for information that is deemed important at the phone numbers or email address I have provided. I understand that these calls/messages are treated by my telephone service provider the same as other general calls/messages I receive for billing purposes according to the phone service plan I maintain with my service provider. I agree that the information shown above fully, accurately and uniquely identifies me in your database. I furthermore agree that my submission of this form, via the 'Submit' button, shall constitute the execution of this document in exactly the same manner as if I had signed, by hand, a paper version of this agreement. Additionally, I understand that I can opt out at any time should I not want to receive these messages.
