Application for membership: DGON

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Application for membership for individual members of the DGON

Personal contact data

Salutation

First name*

Surname*

Date of birth*

Profession/title

Private address

Street/P.O. Box*

No.*

ZIP code*

City*

State*

Phone number

Fax number

E-mail address*

Business contact data

Company / institution

Street/P.O. Box

No.

ZIP code

State

City

Phone number

Fax number

E-mail address

Additional data / information

Special fields of interest

Your interests

Commissions, expert committees or working groups

In which expert committees is cooperation desired?

Membership

Is intended from:*

Individual member of the DGON*

Annual membership fee 80 €

Declaration of consent Data protection

Consent*

I have taken note of the data protection declaration. I agree that my details and data will be collected and stored electronically in order to answer my enquiry. Note: You can revoke your consent at any time for the future by e-mail to dgon.bonn(at)t-online.de.

Don't fill this field!

To the privacy policy

Application for membership

Source: ESOC-MCR-03-12-JMAI-SD / JUERGENMAI.COM

The form uses double opt-in. You will receive an email with a link. You must click the link to confirm that you wish to receive emails from us. Without this confirmation your Application for membership will not be processed.

Application for membership for individual members of the DGON