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Sponsorship programme registration form
(Peterschapsprogramma registratieformulier)
Name:
(voornaam)
*
Surname:
(familienaam)
*
Email:
*
Confirm Email:
(bevestig e-mail)
Phone number:
(telefoon)
*
Street + house number:
(straat + nr.)
*
Postal code:
(postcode):
*
City:
(gemeente)
*
Country:
(land)
*
Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Canary Islands
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic Peoples Republic of
Korea, Republic of
Kosovo
Kuwait
Kyrgyzstan
Lao Peoples Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia (Federated States of)
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin (FR)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Saint-Barthélemy
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (NL)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Island
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Republic of China
Tajikistan
Tanzania, United Republic of
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City State (Holy See)
Venezuela
Viet Nam
Virgin Islands (British)
Virgin Islands (U.S)
Wallis and Futuna Islands
Western Sahara
Yemen
Zaire
Zambia
Zimbabwe
In which language do you want to continue?
(in welke taal wil u verder gaan)
*
English
Nederlands
Zorg er zeker voor dat je adresgegevens 100% juist zijn.
Indien je adres foutief is kunnen wij geen fiscaal attest bezorgen.
Make sure that your address is 100% correct.
If your address is incorrect, we cannot deliver a tax certificate.
Anything else you want to tell?
Heb je nog iets te vertellen?
Waar heb je voor de eerste keer
gehoord van ons sponsorschapsprogramma?
*
Where did you first hear
from our sponsorschip program?
*
YOUR CONTRIBUTION
You can choose how much you donate, the minimum is set at €5 a month which is only €60 a year.
Your donation has to be paid on a yearly base.
UW BIJDRAGE
Je kunt kiezen hoeveel je doneert, het minimum is vastgesteld op € 60 per jaar wat slechts €5 per maand is.
Wij vragen uw bijdrage jaarlijks te betalen.
I donate annualy
€
*
Mijn jaarlijkse bijdrage is
€
*
Totaal te betalen
I have read and understand the
ethical code
:
(Ik heb de
etische code
gelezen en begrepen)
*
TO BE COMPLETED BY LLL
Name of the sponsored child:
*
Child code:
*
Gender
*
boy
girl
Geslacht
*
jongen
meisje
Child age:
*
End sponsorship?
*
dd/mm/yyyy
TO BE COMPLETED BY THE SPONSOR
I confirm that I will sponsor [Child_name] for a year.
I understand that I will be directed towards the secured payment platform
for my annual payment of €[Payment_total].
*
Ik bevestig dat ik
[Child_name] zal sponsoren voor een jaar.
Ik begrijp dat ik doorverwezen wordt naar de beveiligde
betaalpagina voor mijn bijdrage van €[Payment_total].
*
*
=
Input is required
Please use your primary Email address.
Gelieve uw primair e-mail adres te gebruiken.
Minimum €60 & maximum 2.000
Minimum €60 en maximum €2.000
Here you write the enddate of the sponsorship = today + 1 year.