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

 ½ 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.