MSBC HEEP

Postbus 616
6200 MD Maastricht
bestuur@heep.nl
MEMBERSHIP FORM MSBC HEEP
APPLICANT INFORMATION
FIRST NAME:
SURNAME:
GENDER: MALE: FEMALE:
DATE OF BIRTH:
NATIONALITY:
ADDRESS:
POSTAL CODE: CITY:
TELEPHONE:
E-MAIL:
UM/HBO ID-NUMBER:
TYPE OF SPORTS CARD
1
: MONTHS
PAYMENT INFORMATION
SUBSCRIBTION FOR A PERIOD OF:
1 year; from Sept. 01, 2014 until Aug. 31, 2015 for 42.50 per year

year; from Sept. 01, 2014 until Dec 31, 2014 OR Jan 01, 2014 until Aug. 31,
2015 for 20.00 per half year (new member)/29.50 (old member)

I WILL PAY THE MEMBERSHIP FEE OF 42.50 FOR A YEAR/ 20.00/29.50
FOR HALF A YEAR:
CASH
BANK TRANSFER By signing this membership form, I hereby declare that
within fourteen days, I will transfer the membership fee of 42.50 for a year/
20.00/29.50 for half a year into the bank account of MSBC HEEP.
BANK DETAILS:
M.S.B.C. Heep
NL79 RABO 0104 3865 41

DATE: SIGNATURE: ____________________
BOARD MEMBER: DATE:
SIGNATURE: _______________________

1
Possession of a UM SPORT membership Sports is obligatory in order to become a member of MSBC HEEP
and later participate in the sport.