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Recurring Electronic Dues Payment Sign Up

Instructions: Simply fill out the ONLINE form below or Click HERE to download a copy of the form to be mailed or faxed to the VDA central office. 

Renew your VDA membership with recurring direct payments via ACH

(ACH is the electronic transfer of funds from a consumer checking account for the purpose of making a payment.)

Ten Month Plan: 10 (ten) equal automated monthly payments from your checking account.  Payments will deducted by the 15th of each month (January-October) renewed annually. A $25 fee will be applied annually for this service.

Annual Plan: 1 (one) full payment each year from your checking account.  Renewed annually.

Questions: Click HERE to read the most frequently asked question for the recurring payment program.

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If we have questions regarding this form, who can we contact?
9 digit number at the bottom of your check (see illustration above)
Second set of numbers on your check (see illustration above).
Mandatory dues = American Dental Association (ADA), Virginia Dental Association (VDA) and your local component society. Optional contributions = ADPAC, VADPAC, Commonwealth Club
I authorize the Virginia Dental Association (VDA) to electronically debit my account (and, if necessary, electronically credit my account to correct erroneous debits) using the information provided on this form. I understand that this authorization will remain in full force and effect until I notify the VDA in writing that I wish to revoke this authorization. I understand that the VDA requires at least 10 (ten) days prior notice in order to cancel this authorization*. If I choose the 10 Month Plan, I understand that my first debit will be on the 15th day of January and will continue being debited on the 15th of each month there after (January-October annually). I understand there will be a $25 annual fee for this service. Each debit shall be in an amount approximately equal to one tenth of my total dues payment (indicated above) plus the $25 annual fee. If I choose the Annual Plan, the full amount of my dues will be deducted on the 15th of the month after having received and processed at the VDA Central Office. My account will be debited each following year in January for my full dues (indicated above, plus or minus any change in dues amounts). *Written debit authorizations must provide that the Receiver may revoke the authorization only by notifying the Originator in the time and manner stated in the authorization. The reference to notification should be filled with a statement of the time and manner that notification must be given in order to provide company a reasonable opportunity to act on it (e.g., “In writing by mail to VDA Attn: Membership 3460 Mayland Court, Ste 110 Henrico, VA 23233 that is received at least ten (10) days prior to the proposed effective date of the termination of authorization”).

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