Seller Mandate Application by mnh16485

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									     Diploma in Dental Implantology Application Form 2007
           Application no _______________             Date of receipt _______________________
              (Office use only)
                 Please enclose an up to date curriculum vitae and a recent photograph.
                             Selection based on a first come, first serve basis.
             Please complete all pages in BLOCK CAPITALS and tick boxes as appropriate

Title___________         Surname______________________________________________________________
Forename(s)_____________________________________           Date of birth____________________________
GDC number_________________ ____          National registration number (non UK nationals) ____________
Correspondence address_____________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Telephone Daytime _________________________                Evening _________________________________
            Mobile __________________________              Fax _____________________________________
            E-mail __________________________________________________________________________


COURSE OPTIONS
   I wish to complete the Surgical Course - BRONZE                                      £12.995 ex VAT
                                                                        th
                       (£5875 deposit with application and £9394.13 by 7 July 2007)
   I wish to complete the Diploma Course - SILVER                                       £18,500 ex VAT
             (£5875 deposit with application followed by 10 equal monthly payments of £1586.25)
   I wish to complete Specialisation Course - GOLD                                      £23,995 ex VAT
             (£5875 deposit with application followed by 22 equal monthly payments of £1014.51)


QUALIFICATIONS
Degree/diploma _____________________ year ___________ awarding authority ____________________
Degree/diploma _____________________ year ___________ awarding authority ____________________
Degree/diploma _____________________ year ___________ awarding authority ____________________


WORK EXPERIENCE
Hospital posts held




Practice experience




Please describe your practice (max. 50 words)
EXPERIENCE IN IMPLANT DENTISTRY
Experience is not a course requirement. If you have any experience with implants complete the sections below.
Types of cases completed
Single Teeth                 How many?                          Autogenous Onlay Grafts               How many?
Multiple Units               How many?                          Ridge Expansion                       How many?
Ball Atachments              How many?                          Guided Bone Regeneration              How many?
Bars & Clips                 How many?                          Sinus Lifts                           How many?


Do you refer your patients for implant treatment?                        YES                          NO
Do you only refer patients for bone grafting (augmentation)?             YES                          NO
Would you like to make use of the mentoring system on the course? YES                                 NO


Please list implant related post graduate courses you have attended, e.g. conferences, masterclasses,
seminars etc
                                             COURSE(S) & DATES
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
REFERENCES              1.                                                        2.




 THE FOLLOWING SECTION MUST BE SIGNED THE FOLLOWING SECTION MUST BE SIGNED
               •   I certify that the statements made by me on this form are correct
               •   I understand that all deposits are NON-REFUNDABLE
               •   Cancellations must be made in writing
               •   Refunds will not be made if the cancellation is received less than 4 weeks prior to the program
               •   The financial agreement applies to the program fees for the year 2007
               •   I understand that late payments may be subject to a charge
               •   I understand that the program dates are subject to change
               •   I have read and accept PIEL’s terms of business

Please note that all applications are subject to acceptance by Perio-Implant Europe Ltd (PIEL) and all accepted
applications will be regulated by PIEL’s terms of business (attached) and by the details set out in the relevant
course details for each of these courses.
Application and Agreement
I, the Customer, submit my application for the course, as set out above, together with the deposit.

I understand that in all cases, accommodation and travel are not included in the price payable (except where
advised otherwise) and that, depending on the course, any deposit paid is generally not refundable.

I, the Customer, apply to PIEL to join the course as selected by me above and to the terms of business as set out in
this form and the agreement to which it is attached.
I confirm that the information given in this form is complete and accurate.



Signature _________________________________________________________Date ______________________
                                   Perio-Implant Europe Ltd terms of Business
1         Definitions
1.1‘Customer’means the person who buys or agrees to buy the training course from the Seller.
1.2‘Conditions’means the terms and conditions of business set out in this document and any special terms and conditions agreed in writing
by the Seller.
1.3‘Course Date’means the date specified by the Seller (On acceptance of the Customer’s application) when the Course is to be held.
1.4‘Course’means the articles which the training course that the Customer agrees to buy from the Seller.
1.5‘Price’means the price for the Course excluding VAT.
1.6‘Seller’means Perio-Implant Europe Ltd

2         Conditions applicable
2.1       These Conditions shall apply to all contracts for the sale of Courses by the Seller to the Customer to the exclusion of all other
          terms and conditions including any terms or conditions which the Customer may purport to apply under any purchase order
          confirmation of order or similar document
2.2       Any application for a Course shall be deemed to be an offer by the Customer to buy the Course pursuant to these Conditions.
2.3       Acceptance of the Customer’s application shall be deemed conclusive evidence of the Customer’s acceptance of these
          Conditions.
2.4       Any variation to these Conditions (including any special terms and conditions agreed between the parties) shall be inapplicable
          unless agreed in writing by the Seller.


3         The Price and payment
3.1       The Price shall be the price set out overleaf. The Price is exclusive of VAT which shall be due at the rate ruling on the date of the
          Seller’s invoice.
3.2       Payment of the Price and VAT shall be due as provided on this form for the relevant Course. Time for payment shall be of the
          essence and the Seller reserves the right to terminate this agreement forthwith with no liability attaching to the Seller under such
          circumstances if the Customer does not adhere strictly to the payment schedule.
3.3       Interest on overdue amounts shall accrue from the date when payment becomes due from day to day until the date of payment at
          a rate of 2% above (name) Bank plc’s base rate from time to time in force

4         The Course
          The description of the Course shall be as set out in the Seller’s standard application form.

5         Warranties and liability
          The Seller warrants that the Course will at the time of delivery correspond to the description given by the Seller. All other
          warranties, conditions or terms relating to the Course and complying with description and whether implied by statute or common
          law or otherwise are excluded.

6         Holding of the Course
6.1       The Seller reserves the right to vary the times and venue of each Course (or even to cancel a Course altogether) should it be
          necessary for reasons outside its reasonable control to do so eg unavailability of speaker, venue etc. The Seller is not liable for
          any loss suffered by the Customer as a result of any such changes and the Seller will refund any deposit and other payment
          made in full if the Customer is unable to attend the date or venue of a rearranged Course.
6.2       The Seller makes no warranty as to availability of travel to or accommodation at the venue for the Course and the Customer
          accepts full responsibility for ensuring that all required bookings for these are in place before entering into commitment for a
          Course. The Customer warrants that it has made all such enquiries and reservations before submitting this application form and
          that the delegate for the Course will be available to travel to and attend the Course.
7         Exclusion and Limitation of Liability
7.1       The Seller is not liable for any loss suffered by the Customer whether by reason of breach of contract, negligence or otherwise for
          any loss or consequential loss (including loss of profits, damage to reputation or goodwill, loss of business, damages costs or
          expenses or any other indirect or consequential losses) occasioned to any person acting, omitting to act or refraining from acting
          in reliance on the Course or, except to the extent that any such loss does not exceed the Price, arising from or connected with
          any error or omission in the Course or its presentation.
7.2       If any negligence on the part of the Company is established, then the maximum liability on the part of the Company will be determined
          by the maximum indemnity afforded by the Company's insurers.
8         Termination (by Seller) and Cancellation (by Customer)
8.1       If the Customer shall default in making punctual payment of any sum due to the Company under the Contract or these Conditions or
          shall fail to observe and perform any of the terms of the Contract or these Conditions or shall go into liquidation or bankruptcy or do or
          cause to be done or allow any act or thing to be done whereby the Company's ability to hold the Course may be prejudiced then the
          Company may treat this Contract and the Conditions as being repudiated by the Customer and the Company may without any notice
          or other requirement on its part treat the contract as ended but without prejudice to any pre-existing right of the Company against the
          Customer for recovery of monies due or any other breach of the Contract or these Conditions.
8.2       The Customer may cancel this contract at any time by serving notice in writing to that effect. If the notice is given more than 4
          weeks before the Course, then the Customer may be entitled to a refund of the money already paid, depending on the ability of
          the Seller to reallocate the Customer’s reserved place on the Course.

9         Proper law of contract
          This contract is subject to the law of England and Wales.
                          STANDING ORDER MANDATE
                             for Gold Courses Only!

Name of your Bank:      ___________________________________________________________

Bank Address:           ___________________________________________________________

                        ___________________________________________________________

PLEASE TICK THE RELEVANT BOX:                            New Instruction
                                                         Please amend previous
                                                         standing order quoting reference/beneficiary


ACCOUNT TO BE DEBITED

SORT CODE                   -      -

ACCOUNT NUMBER

ACCOUNT NAME


BENEFICIARY DETAILS
        BANK                            Barclays Bank Plc

        BRANCH DETAILS                  Camberley Branch

        ACCOUNT NUMBER                  30487961                   SORT CODE     20-16-99

        BENEFICIARY NAME                Perio-Implant Europe Ltd

        REFERENCE

PAYMENT DETAILS

Amount of First Payment                      £ 1014.51

Amount of Usual Payment                      £1014.51

Date of First Payment                    16TH April 2007


Amount of Usual Payment in Words       One Thousand and Fourteen Pounds and Fifty-One Pence Only.


When Paid (Weekly, Monthly, Annually, etc)          22 Monthly Payments (including first payment)

Date of Usual Payment                    16th of the month

Date of Last payment                    16th January 2009



CUSTOMER SIGNATURE(S)


DATE:                           CUSTOMER CONTACT TELEPHONE NUMBER:


ALL WHITE BOXES MUST BE COMPLETED IN ORDER TO BE PROCESSED
                          STANDING ORDER MANDATE
                             for Silver Courses Only!

Name of your Bank:      ___________________________________________________________

Bank Address:           ___________________________________________________________

                        ___________________________________________________________

PLEASE TICK THE RELEVANT BOX:                              New Instruction
                                                           Please amend previous
                                                           standing order quoting reference/beneficiary


ACCOUNT TO BE DEBITED

SORT CODE                   -      -

ACCOUNT NUMBER

ACCOUNT NAME


BENEFICIARY DETAILS
        BANK                             Barclays Bank Plc

        BRANCH DETAILS                   Camberley Branch

        ACCOUNT NUMBER                  30487961                   SORT CODE       20-16-99

        BENEFICIARY NAME                Perio-Implant Europe Ltd

        REFERENCE

PAYMENT DETAILS

Amount of First Payment                      £1586.25

Amount of Usual Payment                      £1586.25

Date of First Payment              16TH April 2007


Amount of Usual Payment in Words             One Thousand, Five Hundred and Eighty Six Pounds
                                                       and Twenty Five Pence Only
When Paid (Weekly, Monthly, Annually, etc)           10 Monthly Payments (including first payment)

Date of Usual Payment                    16th of the month

Date of Last payment                   16th January 2008



CUSTOMER SIGNATURE(S)


DATE:                           CUSTOMER CONTACT TELEPHONE NUMBER:


ALL WHITE BOXES MUST BE COMPLETED IN ORDER TO BE PROCESSED

								
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