Declaration of Membership

1. Personal Information

Title*

Title

First Name*

Surname*

Date of Birtch

Street /hous no. (personal)*

Postal code Zip-Co (personal)*

City/town (privat)*

Country (personal)*

Country code (personal)

Area code (personal)

Telephone (personal)

E-Mail (personal Correspondence)*

Country code (mobile)

Area code (mobile)

Number (mobile)

2. Reference to the University of Bremen

Type of University Reference*

When did you get your 1st degree at the University of Bremen ?*

Which department did you study in ?

What did you study in your department?

Which degree did you achieve?

3. Job Details

Current Position / Professional Status

Current company

Employed by the company since (year)

Sector of company

Street/house number (on business)

Postcode (on business)

City/town (on business)

Country (on business)

Country code (on business)

Vorwahl (beruflich)

Nummer (beruflich)

E-Mail (alternativ)

4. Membership and contribution category

I choose the following member and contribution category:*

5. payment information

Method of payment

6. data protection

Consent to data protection*

I have read and agree to the data protection .