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Registration form for participation

After application and payment of the registration fee, you will receive a registration code. Keep this code at a safe place and always use the correct code in all mailing and enlisting new members. By completing and signing this agreement form, you are agreeing to participate in the bank program as explained in the information bulletin. The participant is exempted from any financial or other responsibilities concerning the program and the policies.

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Please enter your information below:

Your First Name *
Your Middle Name
Your Last Name *  
Your Birth Date
(dd-MM-yyyy)
*  
 
Title
Address and house no *  
City *  
Postal code *  
Country of Residence *
Telephone *  
 
Number of policies *
Recommended by *  
 

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