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Membership / Renewal Form
PERSONAL INFORMATION:
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Full Name (in English):
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Full Name (in Arabic):
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Gender:
Male
Female
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Date of Birth:
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Nationality:
CONTACT INFORMATION:
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Your Email Address:
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Contact No.:
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Your Country:
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City:
CAREER INFORMATION:
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Salute
Prof
Dr
Mr
Mrs
Ms
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Category
Dental Student
Dental Intern
Dental Assistant
Dental Hygienist
Dental Technician
General Dentist
Specialist
Consultant
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Academic Qualification
Diploma
Bachelor's Degree
Master's Degree
PhD
Fellowship/Board in Dental Specialty
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Pediatric Dentist?
No
Yes
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Nature of Work
Academic (Private)
Academic (Government)
Private
Government
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Do You Have Saudi Commission for
Health Specialties (SCFHS) Number ?
Yes
No
Your SCFHS No.:
PAYMENT DETAILS:
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Subscription
New Membership
Renewal
Your SSPD ID No.:
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Subscription Duration
One (1) Year | 200 SR
Two (2) Years | 400 SR
Three (3) Years | 600 SR
Four (4) Years | 800 SR
Five (5) Years | 1000 SR
BANK DETAILS
Bank Name:
Alrajhi Bank
Account Name:
Saudi Society of Pediatric Dentistry
Account No.:
425608010859970
IBAN No.:
SA96 8000 0425 6080 1085 9970
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Attach Your Payment Receipt Here:
Attached File Not More Than 2MB.
