Mollie_form

Name *

Function

Startdate *

Name Projectleader

KWFprojectnumber *

Institute

Email *

Lodging with breakfast
Yes
No

175
Verblijf met ontbijt (€ 175,00)Verblijf zonder ontbijt (€ 200,00)

Amount *
€

Payment method

I hereby give authorization to collect the amount shown above from my account periodically.

                


                                            
                    
                                            

                            Name*
                            
                        
                    
                                            

                            Company name
                            
                        
                    
                                            

                            Email address*
                            
                        
                    
                                            

                            Phone number
                            
                        
                    
                                            

                            Address*
                            
                        
                        

                            Zipcode*
                            
                        
                        

                            City*
                            
                        
                        

                            Country*
                            
                        
                    
                                            

                            Project
                            GeneralInschrijving met logies                        
                    
                                            

                            Message*
                            
                        
                    
                    

                        Amount €*
€ 100,00€ 150,00                    

                      iDEAL

                    


                    
                     I hereby authorize  to collect the amount shown above from my account periodically.