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ePaper created 2016-10-12, 10:31:46 | version 1.38.0
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: Tel.: +49 241 8088164 Fax: +49 241 803388164 Credit institute: Sparkasse Aachen IBAN: DE56 3905 0000 0042 0339 44 BIC.: AACSDE 33 Membership application form Address: 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 Signature of account holder This declaration is valid until written notice of its revocation Street: ZIP/city: Country: Phone: Fax: E-Mail: Name: BIC: IBAN: Credit institute: Status: self-employed employed civil servant student dental assistant 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 Tel.: +492418088164 Fax: +49241803388164 IBAN: DE56 390500000042033944