Registration Form for Institutional Members

Dear Colleague,

IDEALS appreciates your interest in becoming an institutional member. Please complete the following fields and submit the form. Once we have received this form and your annual dues, we will confirm your membership status.

Welcome to IDEALS and Thank you.

Dr. Jos V.M. Welie
IDEALS Secretary

INSTRUCTIONS: When completing this form, use the mouse or tab to move from field to field. Do not use the ENTER-key until the form has been completed, because it will cause the form to be submitted.

If you wish to become an "Individual Member" please complete this form.

Information about the institution
Name of Institution:
Department:
Address:
Address (continued):
City:
State/Province:
Zip/Postal Code:
Country:
Phone Number:
Fax Number:
Method of Payment Please note: In order to save transfer and other banking charges, members may want to consider paying dues for two years in one payment. Select your preferred method of payment: Account information (to be used for money transfers): Bank Name: Royal Bank of Canada Account Name: International Dental Ethics Routing #: 021000021 Swift Code: ROYCCAT2 Bank #: 003 Transit #: 07437 Account #: 1008036 Mailing Address (for money orders and personal checks): Dr. Milos Lekic Treasurer, IDEALS 780 Bannatyne Avenue Winnipeg, Manitoba R3P 0V5 Canada