Membership Application

I apply for membership in the "Association for the Promotion of Polymer Development and Plastics Technology Central Germany – POLYKUM e. V."

Personal or company membership?*

for me personally

on behalf of the company/institution

1. Personal data of the applicant

Salutation:*

First name/s:*

Last name:*

Date of birth:

Official position in the company/institution:

Company/institution (complete official name):

2. On behalf of a company/institution (complete oﬀicial name)

If you register on behalf of a company/institution, please fill in the following data:

Company**:

Division/subsidiary (if applicable; official name):

Applicator is**:

represented by (if differing from person; part 1):

Salutation:

First name/s:

Last name:

Official position in the company/institution**:

Number of employees of the company/institution or the division applying for membership**:

Official website of the applying company/institution/subsidiary:

Additional Details:

3. Address/Contact data of the prospective POLYKUM member

Address [Street/Place, Number]:*

Additional address data:

Community***:

Province***:

Postal Code:*

City:*

Country:*

Phone No. (icl. country- and citiy-code):*

eMail:*

(Used for current information, fee invoices etc.)

4. Agreements

Start of your membership:*

immediately/date of this application

The membership fee per year is (please mark as appropriate):*

plus Paypal fees when using Paypal (up to 4.8% depending on sender‘s country)

Payment:*

I will pay the membership fee by Paypal or bank transfer after receiving the invoice. POLYKUM will send the invoice to the eMail address cited above.

I confirm that I have read the Privacy policy and revocation notice. (The request is sent to the server encrypted via https. The information will be used to answer the request.

* required
** required for company's or institutional application
*** required for selected countries (e.g. India)

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