NDA Membership Application Form
Title: ...........................................................................................
Surname: ......................................................................................
First Names: ..................................................................................
ID No.: .........................................................................................
Qualifications: ................................................................................
IMDC (Dental Board) Registration No.: .................................................
Dental Protection Member No.: ..........................................................
Practice No.: .................................................................................
P.O.Box: .......................................................................................
City: ............................................................................................
E-mail Address: ..............................................................................
Fax: .............................................................................................
Tel: ..............................................................................................
Signed at __________________________________ on this __________ day
of _________________ 20 _____
Signature_______________________________
Please either print this form, fill in all the details and fax to:
The Secretary of the NDA, Dr. Anna-Marie Oelofsen,
Fax: +264 61 247 965 or copy the form to your e-mail program, complete the details and e-mail to: aoelofsen@iway.na
