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ePaper created 2017-10-26, 15:28:59 | version 1.38.0
Return address: Deutsche Gesellschaft für Laserzahnheilkunde e.V. c/o Universitätsklinikum Aachen Klinik für Zahnerhaltung Pauwelsstraße 30 52074 Aachen, Germany 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 Name/title: Surname: Date of birth: Approbation: Status: Address: Street: ZIP/city: Country: (cid:133)(cid:3)self-employed (cid:133)(cid:3)employed (cid:133)(cid:3)civil servant (cid:133)(cid:3)student (cid:133)(cid:3)dental assistant Phone: Fax: E-Mail: With the application for membership I ensure that (cid:133)(cid:3)I am owing an own practice since _______________________ and are working with the laser type ________________________________________________________________ (exact name). (cid:133)(cid:3)I am employed at the practice ___________________________________________________________________ (cid:133)(cid:3)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