Contract BLMV 1 request to become a Buitengewoon Lid Mijnbouwkundige Vereeniging (extraordinary member of the Mijnbouwkundige Vereeniging) and therefore agree on paying the yearly contribution. In case that you are already a BLMV member; this form permits the MV to debit the yearly contribution from your bank account by pre-authorized debit transaction. The contribution amounts minimal BUR 25,00 a year, for which the named below receives a yearbook with a hard cover, as well as the magazine of the Mijnbouwkundige Vereeniging named “Natural Resource”. The named below will also get access to the digital database of the Mijnbouwkundige Vereeniging Surname : Prabhakaran Employer Name : Rahul Function Initials NA Address work Title Mr Zipcode/City Address Korveezeestraat 261 E-mail: Zipcode! City 2628 DM / Delft Phone Phone number 2431 - 687916682 E-mail + rahul.mexxian@gmail.com Graduation year: 2016 By signing this form I give the Mijnbouwkundige Vereeniging permission to debit the yearly contribution from my bank account. Name : Mijnbouwkundige Vereenigin: Incassant ID : NL39ZZZ403972650000, Authorization characteristic :{ ][ ][ ][ ] (1o be completed by the secretary or treasurer) IBAN :NL23 ABNA 0621 813699 Bank Identificatie BIC* Place and date : Delft Signature : Y * Goen verplicht veld bj NLIBAN