implants - international magazine of oral implantology International Edition

German Association of Dental Implantology Founded in 1970 Please send your Membership application to: DGZI e.V. Paulusstr. 1 40237 Düsseldorf GERMANY Central Office & Secretary of the Board DGZI e.V. Paulusstr. 1 40237 Düsseldorf Germany Phone: +49 211 16970 –77 FAX: +49 211 16970 –66 office@dgzi-info.de www.dgzi.de MEMBERSHIP APPLICATION FORM Please fill out this application form in print letter, thank you. Name Title Date of birth Street Country Phone, country and city code E-mail First name Citizenship City, zip code FAX Homepage PERSONAL DATA Do you have experience in Implantology? o Yes o No MEMBERSHIP FEE Hereby, I want to apply for the membership in the DGZI. o Full member (outside Germany) – 125 Euro p.a. o Students/Auxiliaries (outside Germany) – 60 Euro p.a. AGREEMENTS Herby I agree to publish of my personal data in all concerns of the DGZI e.V.! PAYMENT Special qualification Spoken languages Sign City of sign, Date By credit card: Card holders name Card no Expiry date / Please use your: (make a cross by the card u want to use) Visacard c Mastercard c By check: Please send a check to the DGZI central office (address in the top) in amount of the membership fee in US Dollar. Kennung