MEMBERSHIP APPLICATION

Applicant

Gender
FemaleMale

Surname, First name (*)
Street address (*)
ZIP Code (*)
City (*)
Telephone number (*)
Email (*)

Dates and family members

Is one of the persons living in the household incurably chronically ill or is currently under medical treatment?
YesNo

Surname, First Name Relationship Date of birth Birthplace Nationality If yes, type of disease
Applicant
Partner
SonDaughter
SonDaughter
SonDaughter

Children under 18 years are accepted without certificate, from 19 - 27 years only with school certificate or study certificate.

Admission fee

Age 18 -- 29 0,00 Euro One-time admission fee Plus 89.95 Euro Yearly
Age 30 -- 49 49,95 Euro
Age 50 -- 54 399,95 Euro
Age 55 -- 59 599,95 Euro
Waiting period 180 days (6 months) after commencement of membership.

Preferred method of payment

ÜberweisungSEPA-Lastschriftmandat

I / We authorize you (on) to receive payments from my (our) direct debit account. At the same time as (n) I / We, my/our institution / Bank to repay the Pikellimi GmbH from my / our withdrawn account. Note: I / We can, within eight weeks from your debit date, refund the amount charged. Applicant agreed with my/our/institution financial terms.

Name of the Bank: IBAN:
Account holder if different:

I have read and agree to the general terms and conditions of Pikellimi GmbH. AGB LINK