Extensus Registration Form
Personal Information
Full Name
*
First Name
Last Name
E-mail
*
example@example.com
Phone Number
*
-
Country Code
Phone Number
Date of Birth
*
-
Day
-
Month
Year
dd-mm-yyyy
Address
*
Street Address
Street Address Line 2
Postal / Zip Code
City
Gender
*
Female
Male
Other/Prefer not to say
Academic Information
University
*
Please Select
UvA
VU
AUC
Student Number
*
Bachelor Study Programme
*
Master Study Programme (if applicable)
Academic year started
*
Expected graduation in academic year
*
Payment Details
Bank Account Number (IBAN)
*
Name of your Bank (if you don't have a Dutch bank account
I hereby authorize and request Honours Programme Study Association Extensus to make annual SEPA withdrawals of 25 euros yearly by initiating debit entries to my account indicated on the form provided. I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify in writing of any changes in my account information or termination of this authorization at least 14 business days prior to the next billing date. I certify that I will not dispute these scheduled transactions; so long as the transactions correspond to the terms indicated in this authorization. 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. Your rights regarding this mandate are explained in a statement that you can obtain from your bank.
*
Yes
*
Additional
How did you hear about us?
*
Friends
Social Media
Website
Presentation
Canvas
Other
Why are you joining Extensus?
*
Honours Friends
Professional events
Social Events
Academic events
Borrels
Other
Are you interested in joining a committee?
*
Please Select
Yes, the Events Committee
Yes, the Commercial Committee
Yes, the PR committee
Maybe
No
*
Treasurer
Register
Register
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