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ePaper created 2016-01-07, 12:59:38 | version 1.38.0
Membership Application Form I hereby to apply for membership of the DGZI – German Association of Dental Implantology (Deutschen Gesellschaft für Zahnärztliche Implantologie e.V.). Please send this form via FAX to +49 211 16970-66. Do you have experience in implantology? (mandatory) Yes No I hereby agree to have my personal data processed for all purposes of the DGZI. Full membership (outside Germany) Assistant doctors (outside Germany) Students/auxiliaries (outside Germany) 125 Euro p.a. 60 Euro p.a. 60 Euro p.a. 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 Personal Data Deutsche Gesellschaft für Zahnärztliche Implantologie e.V. Central Office: Paulusstraße 1, 40237 Düsseldorf, Germany Phone: +49 211 16970-77 | FAX: +49 211 16970-66 | office@dgzi-info.de | www.dgzi.de FOR FURTHER INFORMATION PLEASE CONTACT Name First name Date of birth Title Citizenship Street City, ZIP code Country Phone, Country and Area code Fax E-Mail Homepage Special qualification Spoken languages Payment (by credit card) Please use your: (Please mark as appropriate) Visa MasterCard Card holder’s name Card number Expiry date Signature Place, Date IM 4/15 Please complete this application form in block letters. Please send this form via FAX to +4921116970-66. IBAN: DE33 573510300050030436 | KSK Altenkirchen | SWIFT/BIC: MALADE51AKI Phone: +4921116970-77 | FAX: +4921116970-66 | office@dgzi-info.de | www.dgzi.de