ClubCollect

Title

Initials

First Name

Infix

Last Name (required)

Gender (required)

Male

Female

Rather not say

Date of Birth

Contact Email (required)

Phone 1

Country Code (required)

Phone Number

Find Address

Type in some of your address details to locate your address

Address line 1 (required)

House No. *

Extension

Address line 2

Postcode (required)

City (required)

Country

Payment Type

IDEAL

Automatische incasso

IBAN (required)

I am the bank account holder or custodian.
By signing this mandate form, you authorise (A) ClubCollect to send instructions to your bank to debit your account and (B) your bank to debit your account in accordance with the instructions from ClubCollect. 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.

Type of Membership (Subscription/Plan) (required)

3x3Groningen Jersey (required)

Additional Info