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 119.95 Euro Yearly Age 30 -- 49 49,95 Euro Age 50 -- 54 399,95 Euro Age 55 -- 59 899,95 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 At the same time as (n) I / We, my/our institution / Bank to repay the Pikellimi GmbH from my / our withdrawn account.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. AGBLINK Δ