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ePaper created 2016-07-29, 16:53:04 | version 1.38.0
Tel.: +49 241 8088164 Fax: +49 241 803388164 Credit institute: Sparkasse Aachen IBAN: DE56 3905 0000 0042 0339 44 BIC.: AACSDE 33 Return address Deutsche Gesellschaft für Laserzahnheilkunde e.V. c/o Universitätsklinikum Aachen Klinik für Zahnerhaltung Pauwelsstraße 30 52074 Aachen, Germany Name/title: Surname: Date of birth: Approbation: Status: self-employed employed civil servant student dental assistant Address: Practice/office/institute (delete as applicable) ZIP/city: Phone/fax: Private/place: Street: Email: Street: Due to an association agreement of DGL and DGZMK, an additional reduced annual fee for DGZMK is charged (€ 85 p.a. if you are not yet a member of DGZMK). The contribution collection is made by the DGMZK office, Liesegangstr. 17a, 40211 Düsseldorf, Germany. You will be addressed hereby. With the application for membership I ensure that I am owing an own practice since and are working with the laser type (exact name) I am employed at the practice I am employed at the University I apply for membership in the German Association of Laser Dentistry (Deutsche Gesellschaft für Laserzahnheilkunde e.V.) Place, date Signature Annual fee: for voting members with direct debit €150 In case of no direct debit authorisation, an administration charge of €31 p.a. becomes due. DIRECT DEBIT AUTHORISATION I agree that the members fee is debited from my bank account Name: BIC: IBAN: Credit institute: Signature of account holder This declaration is valid until written notice of its revocation Membership application form (English) Tel.: +492418088164 Fax: +49241803388164 IBAN: DE56 390500000042033944