Hereby, I apply for the membership into the DOG / the German Ophthalmological Society.

Salutation* Ms Mr
Name*
First Name*
Title
EFN
Date of birth*

Addresses

Institution Address

Type of InstitutionClinicPracticeResearch Institution (without healthcare provision)Others


Institution*

Department
Function
Street, Street number*
Postal Code*
City*
Country
Phone (incl. area code)
Mobile (incl. area code)
Fax (incl. area code)
Email*

Private Address

c/o
Street, Street number*
Postal Code*
City*
Country
Phone (incl. area code)
Mobile (incl. area code)
Email*

Address to be used*

for letters: institution private
for magazines: institution private
for the members directory: institution private no entry at all

Certification / Residency*

Ophthalmologist Ophthalmologist Resident Scientist working in visual research Others
Certification / Residency since*
Residency institution*
Please specify "others"

Magazine subscription

Please select your journal Der Ophthalmologe Graefes Archive Der Ophthalmologe und Graefes Archive (for additionally 60 Euro per year)

Please note:

Your application can only be processed, if you designate two references, who should be members of the German Ophthalmological Society, as well.

1st reference*
Title, First Name, Name
Address

2nd reference*
Title, First Name, Name
Address

By sending this form, you consent that for handling your application, we will process and store your data as outlined in our privacy policy and contact you at your return address. We will delete the data when it is clearly visible that your request has been settled or in case your consent is revoked or if you object to the further processing of your data. For further information, please see our privacy policy.

Consent for data processing by the DOG for the transmission of the Association’s members’ newsletter which appears at irregular intervals and other information for members of the Association to email addresses I provide.