TITLE

SURNAME

FIRST NAMES

ID NO

LABORATORY ADDRESS

POSTAL ADDRESS

OCCUPATION

DENTASA Membership no.

TELEPHONE NUMBERS

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FAX    

CELL

E- MAIL

LABORATORY

NAME

SADTC REG. NO.

LABORATORY OWNER

EMPLOYEE

DENTASA MEMBERSHIP LAPSES ANNUALLY ON 28th FEBRUARY.

MEMBERSHIP IS TO BE RENEWED ANNUALLY FROM 1 MARCH, WHEN THE ANNUAL MEMBERSHIP FEE OF

R 900.00 for LABORATORY OWNERS

R 450.00 for EMPLOYEES

R60.00 for STUDENTS

is PAYABLE

NEW MEMBERS R100.00 ONCE OFF JOINING FEE

BANK DETAILS FOR DIRECT DEPOSITS, AND/OR ELECTRONIC PAYMENTS :

¨        DENTAL TECHNOLOGY ASSOCIATION OF SOUTH AFRICA

¨        ABSA BANK, Brooklyn ¨        ACCOUNT NUMBER : 15-0018-4686

¨        BRANCH CODE: 630345

KINDLY RETURN / FAX COMPLETED FORM TO (012) - 460 9481 FOR PROCESSING

AND ISSUING OF MEMBERSHIP NUMBER