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ePaper created 2016-11-23, 14:26:06 | version 1.38.0
Membership Application Form I hereby to apply for membership of the DGZI – German Association of Dental Implantology (Deutsche 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. free of charge for first-degree students of dentistry 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 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 Please complete this application form in block letters. 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 IM 4/16 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