(Please Tick)

New Members Application

or

Renewal/Update

Title:

Initials:

Surname:

First Name:

ID No:

Postal Address:

Telephone Numbers:

Work:

Fax:

Cell:

E-mail:

Laboratory/University Name:

SADTC LA No:

SADTC Registration Certificate Number (TE No.)

DENTASA Membership No:

Occupation (Please Tick)

Contractor

Employee

Lecturer

Student

If you are a student please tick year of study

1st Year

2nd Year

3rd Year

4th Year

Would you like to receive E-Alerts?

Yes, I would like to receive the communication e-mail:

No, I do not want to receive the communication e-mail:

Would you like to receive SMS's?

Yes, I would like to receive the sms communication:

No, I do not want to receive the sms communication:

Please note:

Different information is communicated through e-mail and sms. You will not receive the same information through e-mail and sms communication. It is your responsibility to inform the office should any changes occur in your personal details, especially your e-mail address and cell phone number.

Membership stays valid and payable until a written resignation is received.

DENTASA membership now lapses annually on 31 December.

New members pay a R100.00 once off joining fee (excluding students).

We do have a Debit Order facility for monthly deductions. Get your form from our Web site.

Bank Details

Account holder name: Dental Technology Association of South Africa

Bank: ABSA Bank, Brooklyn

Account Number: 15-0018-4686

Branch code: 33-53-46