Dtai Member Application Form 2010
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Membership Application Form 2010 Entrance fee
€ 350.00
From 1st January 2010 until 31st December 2010
€ 350.00
Total first year
€ 700.00
Change of Details Fee
€10.00
The entrance fee is one off. If a membership lapses the entrance fee is payable again to rejoin.
All fees are strictly due to be received by 31st December of each year. Please write clearly Surname……………………………………………………………………………………. First name…………………………………………………………………………………... Address……………………….............................................................................................. ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… Telephone number…………………………………………………………………………. Fax number…………………………………………………………………………………
Mobile number……………………………………………………………………………... E-mail address……………………………………………………………………………… Laboratory name…………………………………………………………………………… Employer name…………………………………………………………………………….. Irish Medicines Board registration number………………………………………………... Do you wish your details to be shown on the Dental Technicians Association Ireland website www.dtai.ie ? Please tick Yes
No
For information on the website. What type of work do you do in your laboratory? Please tick Prosthetics
Cobalt Chromiums
Crown and Bridge
Orthodontics
Signed………………………………………………………………………........................ Amount enclosed…………………………………………………………………………... Please make payable to ‘D.T.A.I.’ Date…………………........... Send this application form with your payment to:The Membership Secretary D.T.A.I The Dental Suite 5 Fitzwilliam Terrace Strand Road Bray County Wicklow
€ 350.00
From 1st January 2010 until 31st December 2010
€ 350.00
Total first year
€ 700.00
Change of Details Fee
€10.00
The entrance fee is one off. If a membership lapses the entrance fee is payable again to rejoin.
All fees are strictly due to be received by 31st December of each year. Please write clearly Surname……………………………………………………………………………………. First name…………………………………………………………………………………... Address……………………….............................................................................................. ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… Telephone number…………………………………………………………………………. Fax number…………………………………………………………………………………
Mobile number……………………………………………………………………………... E-mail address……………………………………………………………………………… Laboratory name…………………………………………………………………………… Employer name…………………………………………………………………………….. Irish Medicines Board registration number………………………………………………... Do you wish your details to be shown on the Dental Technicians Association Ireland website www.dtai.ie ? Please tick Yes
No
For information on the website. What type of work do you do in your laboratory? Please tick Prosthetics
Cobalt Chromiums
Crown and Bridge
Orthodontics
Signed………………………………………………………………………........................ Amount enclosed…………………………………………………………………………... Please make payable to ‘D.T.A.I.’ Date…………………........... Send this application form with your payment to:The Membership Secretary D.T.A.I The Dental Suite 5 Fitzwilliam Terrace Strand Road Bray County Wicklow
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