Fields marked with * are required fields.

First name(s):*
Family name:*
Gender:* Male
Female
Other
Street and house number:*
Zip code:*
City:*
Country:*
Date of birth:*
Email address:*
Student number:*
(not your "aaa000" VUnet ID)

Study programme:* Biology
Biomedical sciences
Other, please specify:
Year of enrollment:*
Telephone number:
Mobile phone number:*
(e.g., +31 6 12345678 in case
of an international number)

Today's date:*

Undersigned hereby agrees to an annual direct debit of the contribution of 10 euro and the potential made coffee/tea costs by faculty association Gyrinus natans.
If the amount of contribution will change on the GeneralMembersMeeting, this will be announced by e-mail.
Cancellation of the membership can be done by an e-mail to the board and has to be done before the 1st of October of the new academic year.
The membership will be automatically extended when it is not cancelled.

Name account holder:*
City account holder:*
Bank account number (IBAN):*
BIC:*
(See www.iban.com/search-bic)

Bank:*
Signature account holder:*
Date and place of signature:*

1SEPA, Incassant ID: NL18ZZZ343280170000. Refund period is 56 days, kind authorisation: continuous autorisation.
2Aforementioned bank account will be used for the direct debit of the annual contribution and the potentially made coffee/tea costs.
If you pay this yourself you should fill in your own data, if anyone else pays this you should fill in their data.

Undersigned hereby agrees that personal data will be kept by the board of Gyrinus natans.
For more information about privacy, consult the privacy policy on Gyrinus.nl/privacy.

Signature:*


Form by Boet Sprenkeling, summer 2019. Version 1.2.
ITcie 2017 - 2019.
Please report any issues to the Gyrinus board, room P-022 (W&N building), or to me.
Comments and suggestions are also appreciated.