Individual membership

Individual membership

» to the membership application form for associations

Please fill out the form below if you want to become a member of the PATIENTE VERTRIEDUNG asbl.

Title

Name (Musterman)

First name (Max)

Social security number (1980 01 01 000 00)

Civil status

Nationality

Phone (+352 49 14 57 1)

E-Mail (info@patientevertriedung.lu)

First name of the partner (Max)

Last name of the partner (Mustermann)

Social security number (1980 01 01 000 00)

Nationality

Phone (+352 49 14 57 1)

E-Mail (info@patientevertriedung.lu)

Number of children

Name of the first child (Max Mustermann)

National security number (1980 01 01 000 00)

Name of the second child (Max Mustermann)

National security number (1980 01 01 000 00)

Name of the third child (Max Mustermann)

National security number (1980 01 01 000 00)

Name of the fourth child (Max Mustermann)

National security number (1980 01 01 000 00)

Name of the fifth child (Max Mustermann)

National security number (1980 01 01 000 00)

Street and N° (1B, rue Thomas Edison)

Postal code (L-1445)

City (Stassen)

Country

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The annual membership is 25 € for a person and 38 € for a family.

(Our annual subscription year runs from January to December and future subscription payments are due in January regardless of when you first joined. You will automatically receive payment instructions in the subsequent years. We will send you your membership card as soon as we have received your payment.)

Please wire transfer the corresponding amount into one of our following IBAN bank accounts:

CCPL LULL	LU02 1111 1249 7236 0000
BGLL LULL	LU67 0030 7221 0470 0000
BCEE LULL	LU07 0019 6100 0075 5000

Individual membership – 25 €

Annual family membership – 38 €

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