Online Registration

PERSONAL INFORMATION

Gender

Name and Surname *

Member no. ( if any )

Name of the disease, if any *

Address *

Postcode *

City *

Phone *

E-Mail *

Date of Birth

Place of Birth *

National Status *

INFORMATION ON FAMILY FERRIES THAT CAN BENEFIT FROM ASSISTANCE

1 Click

Degree of Proximity

Name and Surname

Date of Birth

Place of Birth *

Name of the disease, if any *

2 Click

Degree of Proximity

Name and Surname

Date of Birth

Place of Birth *

Name of the disease, if any *

3 Click

Degree of Proximity

Name and Surname

Date of Birth

Place of Birth *

Name of the disease, if any *

4 Click

Degree of Proximity

Name and Surname

Date of Birth

Place of Birth *

Name of the disease, if any *

5 Click

Degree of Proximity

Name and Surname

Date of Birth

Place of Birth *

Name of the disease, if any *

6 Click

Degree of Proximity

Name and Surname

Date of Birth

Place of Birth *

Name of the disease, if any *

I consent to the evaluation and use of my application data by third parties for market research and advertising, although it does not affect the contract and reserves the right to cancel at any time.

BANK DETAILS

Name of account owner

Bank

IBAN * IBAN geçersiz | Ihre IBAN ist ungültig IBAN doğru | Ihre IBAN ist korrekt

BIC

I furthermore authorize BKUG to directly debit my bank account (SEPA).

By submitting this registration form, I hereby declare that I have read and accepted the specifications of the UQBAH Funeral Assistance Association in this connection

I hereby confirm that all information provided by me and my family members is complete and correct.

Clicking the submit button does not mean that your registration is accepted, we will be notified in writing to your address.

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