Bay of Quinte Dentist Association Member Sign-up by Cheque

Please complete the form below to pay your annual Bay of Quinte Dentist Association Membership Fees by Cheque. Forward your cheque to:

Dr. Marc Zechel
208 Bridge Street East,
Belleville, ON  K8N 1N8

Unless otherwise indicated in the comments section this information collected will be used to populate your Directory Listing.

First Name*

Last Name*

Address*

City*

Postal Code*

Email Address*

Phone*

Your Website Address:

Photo or Logo (this will appear in the directory)

 

Annual Member Fee

$250.00

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