Registration form
(please write in capital letters)
Yes, I would like to join student society SoSalsa. My personal data is:
☐ Male ☐ Female
First name
Last name
Initials
E-mail
Date of birth
-
-
Phone number
Address ____________________________________________________________________________________
Postal code
City___________________________________________________________
I am a: ☐TU Delft Student(Bachelor/Master)
☐ Non-TU Delft Student
☐TU Alumni
☐ Other
☐TU employee/PhD
Study _______________________________________________ ☐ Bachelor
☐ Master
☐ PhD
Institution ___________________________________________
Student number
Your membership will automatically be extended unless you cancel your membership at least one full
calendar month prior to the end of your membership period.
Bank information:
IBAN
Owner of bank account ____________________________________________________________________________
Payment:
Authorized debit
☐ I hereby authorize SoSalsa to collect the following amount from my account until termination of the
membership contract (see Appendix A):
Direct paymen
Pin
☐ € 25,00 per half year TU Delft Student.
☐ € 35,00 per half year Others
cash
☐ € 25,00 per half year TU Delft.
☐ € 35,00 per half year Others
☐ I have read and understand the terms of agreement concerning the membership fee (Appendix B)
Date
Signature new member
Signature SoSalsa
__________________________
_______________________
Your data will not be shared with third parties and will be treated with utmost care and trust.