Thank you for returning the compltete form
Transcription
Thank you for returning the compltete form
Association des Assistants(es) Dentaires du Québec 7400, boul. Les Galeries d’Anjou, bureau 410, Montréal (Québec) H1M 3M2 Téléphone: 514-722-9900 Télécopieur: 514-355-4159 [email protected] | www.aadq.ca STUDENT ADHESION FORM Capital letter please PERSONNAL INFORMATION Name : First name : Address : City : Province : Postal code : Birth date : Email : Home phone number : STUDIES School’s name: Graduation year : The annual student fees for the association are $50.00 ($25 from it will be sent to the National association CDAA). A receipt will be sent to you for your income taxes report. rst The annual fee is valid from April 1 to March 31 of each year. You need to include the proof that you are registered in a dental assistant course. Payment by check Please make your check to the Association of dental assistants of Quebec Check of $50.00 Credit card payment Please note that the information listed below will be destroyed once transaction complete VISA MASTERCARD Holder’s name Card numbers Expiration date Security card numbers SIGNATURE NAME DATE If you have any questions, please contact us Thank you for returning the compltete form: By email at : [email protected] By fax :: 514-355-4159 By mail : 7400, boul. Les Galeries d’Anjou, bureau 410, Montréal (Québec) H1M 3M2