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.
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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