Nepal Samaj Nederland E-mail: [email protected] Website: www.nepalsamaj.nl KvK: 09108187, Gelderland Rabobank account: 157850641 Membership form Please use capital letters when you fill in this form. Do not forget to put your signature after having filled in the form. Send this form by post to NSN t.a.v. Juna Shrestha, Pieter Aertszstraat 59-2 1073 SK Amsterdam, or send it by email [email protected] You might want to keep a copy of this form for your own administration. First name M/F Last name Street and house number Postal code and place Telephone number E-mail Date: Signature: Membership contributions The NSN-membership contribution is € 20 a year per household. Money transfer ❏ I will transfer the contribution as soon as possible to the following bank account, Rabobank account 15 78 50 641 t.n.v. NSN Leiden o.v.v. ‘lidmaatschap’ and will transfer the amount every year to the account of NSN till I decide to quit the membership. If I quit being a member of NSN I will do so by writing a letter at least one month before the end of the calendar year to the address mentioned above. Authorization ❏ I would like to make use of the following authorization form and give NSN the permission to withdraw the membership contribution from my bank account every year till I decide to quit my membership. The following person gives Nepal Samaj Nederland permission to withdraw the membership cost, € 20, once a year from his/her mentioned bank/giro account for being a member. Bank account / Giro account Last name and first name’s initials Address Postal code and place Date Signature
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