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Contract insurance

* Mandatory field.
(1) Fiels for minors.
Status*
Minor Adult
Title  
Surname* 
Name* 
Father's Name (1) 
Mother's Name (1) 
Profession 
Birthdate 
Birthplace 
Postal Address 
E-mail 
Phone Number 
Attendance school. (1) 
Are you carrying the
HIV virus?
No Yes
Blood group
A B AB O Unknown
Selected benefits 
   
Banking account of Medi-Aid
Account number:  200714767
Banking Code:  51350025
Banking Institute:  SPARKASSE GIESSEN
   
IBAN:  DE05513500250200714767
BIC/SWIFT:  HELADEF1GIE
   
 I recognize that all given informations are true and i promise to transfer the amount corresponding to the selected performance in the account given above
   
Additional information to MEDI-AID
   
   
   
www.medi-aid.org