Application for Membership in the 
German Society for Electron Microscopy e.V.
(http://www.dge-microscopy.de)
To the DGE Managing Director
Prof. Dr. Benjamin Butz 
Universität Siegen
Adolf-Reichwein-Straße 28
57076 Siegen

I  apply for membership in the DGE as:

(	)	Individual membership / scientist (Annual Fee € 80) 
(	)	Technical staff member (Annual Fee € 40)
(	)	Student or Retiree/Pensioner (Annual Fee € 23)
Students are asked to include a copy of proof of enrollment with the membership application.
		For company membership, please directly contact the secretariat. 

(	)	I additionally apply for membership in the European Microscopy Society EMS (http://www.eurmicsoc.org) at an additional annual fee of 7 € 
(The current terms, conditions, and membership fees of the EMS apply)

Female
Male	Title:....................First Name:......................................Family Name:……................................

Profession / Discipline:........................................................................Date of Birth:......................................

Address:.......................................................................................................................................….…….

E-Mail:.......................................................................................................................................................
I consent to the storage, transfer, and processing of my personal data for the purposes of society membership. Upon admission to the DGE, I acknowledge and expressly accept the statutes and society regulations, the membership fee regulations, and the currently applicable membership fee rates.

Date:.................................. Signature:......................….................................................

SEPA Direct Debate Mandate for the collection of membership fees by direct debit:
I authorise the DGE to collect payments from my account by direct debit. At the same time, I instruct my bank to honour the direct debits drawn on my account by the DGE. Note: I am entitled to a refund of the debited amount within eight weeks from the date of the debit. The terms and conditions agreed with my bank apply.
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Bank Name	BIC

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Written Name or Firm Stamp	Date	Signaturet