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implants_international magazine of oral implantology No. 2, 2016

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 2/16 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

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