Cacaofabriek - Purchase membership card

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Fill out the form below and click 'Next'.

Card type

Sex

Man

Vrouw

Birth date

Initials

First name

Middle initials

Last name

Zip

Address line 1

Address line 2

Address line 3

City

Email address

Confirm email address

phone1_label

filmkring_dagdeel_label

Photo

Upload a recent photograph for your membership card.

Direct debit?

Nee

	SEPA Core Direct Debit
	You must pay the membership fee for the first year now. The mandate is used to renew your membership card on the due date.
IBAN	Enter IBAN to use for this mandate.
Account name	Name associated with bank account for this mandate.
	By signing this mandate form, you authorise Cacaofabriek Helmond to send instructions to your bank to debit your account and authorise your bank to debit your account in accordance with the instructions from Cacaofabriek Helmond. As part of your rights, you are entitled to a refund from your bank under the terms and conditions of your agreement with your bank. A refund must be claimed within 8 weeks starting from the date on which your account was debited.

Continue to confirmation page.