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implants - international magazine of oral implantology

By credit card: Card holder’s name Card number Expiry date / Please use your: (Please mark as appropriate) Visa c MasterCard c German Association of Dental Implantology (Deutsche Gesellschaft für zahnärztliche Implantologie e.V., DGZI) 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 complete this application form in block letters. NAME TITLE DATE OF BIRTH STREET COUNTRY PHONE, COUNTRY AND AREA 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 I wish to apply for membership of the DGZI. o Full membership (outside Germany) – 125 Euro p.a. o Students/auxiliaries (outside Germany) – 60 Euro p.a. o I have transferred the annual fee to the DGZI bank account c/o Dr Rolf Vollmer: IBAN: DE33 5735 1030 0050 0304 36 | KSK Altenkirchen | SWIFT/BIC: MALADE51AKI AGREEMENTS I hereby agree to have my personal data processed and pub- lished for all purposes of the DGZI. PAYMENT SPECIAL QUALIFICATION SPOKEN LANGUAGES SIGNATURE PLACE, DATE Implants 2/14

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