Online Registration

PERSONAL INFORMATION


Gender

Name and Surname *

Name of the disease, if any *

Address *

Postcode *

City *

Phone *

E-Mail *


Date of Birth

Place of Birth *

National Status *

Occupation

INFORMATION ON FAMILY FERRIES THAT CAN BENEFIT FROM ASSISTANCE


Are any of your family members treated for a chronic condition?

1 Click

Degree of Proximity

Name and Surname


Place of Date

Place of Birth *

Name of the disease, if any

2 Click

Degree of Proximity

Name and Surname


Place of Date

Place of Birth *

Name of the disease, if any

3 Click

Degree of Proximity

Name and Surname


Place of Date

Place of Birth *

Name of the disease, if any

4 Click

Degree of Proximity

Name and Surname


Place of Date

Place of Birth *

Name of the disease, if any

5 Click

Degree of Proximity

Name and Surname


Place of Date

Place of Birth *

Name of the disease, if any

6 Click

Degree of Proximity

Name and Surname


Place of Date

Place of Birth *

Name of the disease, if any



I consent to the evaluation and use of my application data by third parties for market research and advertising, although it does not affect the contract and reserves the right to cancel at any time.

Altersgruppen

OUR BANK DETAILS

London Islamic Culture And Recreation Society

Bank Name: HSBC
Account Name: LICARS
Account No: 31585185
Sort Code: 40-43-35

Payment subject: The annual fee or registration fee
Reference: Member Name, Surname and No



Clicking the submit button does not mean that your registration is accepted, we will be notified in writing to your address.
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