Membership

Application for membership

Type of Membership

I apply for…

a full membership.
a supporting membership.

Details on the person

Mr.
Mrs.

Title

Name

First Name

Institution

Occupation

Street

Number

ZIP

City

Telefon

E-Mail

Reference

You need the reference of a member of CBASP-Netzwerk e.V. for your membership application to be accepted. You may ask the trainer of a CBASP workshop at which you have taken part for a reference

Name

Data Protection

We can publish your name on the homepage if you are a certified CBASP-therapist if you want. Do you want that?

yes, I do
no, I don`t

Banking Connection

You can by your membership fee by debit or transfer money to the CBASP network account. Please contact us if you need further information.

Account Holder

Account Number

Bankcode

Name of Bank

Preauthorized payment mandate

I hereby authorize the CBASP network to withdraw the membership fee from my account on the payment due date.

Date

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