Membership Application

1. Membership type

I apply for membership* in the "Verein zur Förderung der Polymerentwicklung und Kunststofftechnik in Mitteldeutschland - POLYKUM e.V."

for me personally

for a company / an institution

2. Applicant's personal data

Salutation:*

First name/s:*

Surname:*

Email:*

Phone:

Occupation:

Date of birth:

3. Data of the company / institution

Company (full official name):*

Division / subsidiary:

Applicant is:*

Represented by (if different from data in part 2):

Salutation:

First name/s:

Surname:

Occupation:

Email:

Phone:

Number of employees* of the company / institution or department / subsidiary:*

Official website of the applicant:

Additional information:

3. Contact details of the prospective POLYKUM member

Street and address number:*

Address suffix:

Postal code:*

City:*

Community:

Province:

Country:*

Website:

4. Membership fee

Selection of the appropriate annual contribution:*

Contribution payment:*

By invoice

By direct debit

IBAN:*

BIC:*

Bank name:*

Note:

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.

* Mandatory field

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