Registration – Extensus

Register to become a member of Extensus! The annual membership fee is only €12, for which you will get to join all our social, academic and professional events!

Personal Information
Name *

First Name Last Name
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City

Postal / Zip Code
Phone Number *
Gender *

Male Female Other/Prefer not to say
Date of Birth *

Day Month Year
dd-mm-yyyy
Academic Information
University *
Bachelor Study Programme *
Academic Year Started *
Master Programme (if applicable)
Student Number *
Payment Details
Bank Account Number (IBAN) *
Name of Your Bank (if you don't have a Dutch bank account)
I hereby authorize and request Honours Programme Study Association Extensus to make annual withdrawals in the amount listed above by initiating debit entries to my account indicated on the form provided. *

Yes
Additional
Would you like to become an active member (e.g. join an Extensus committee)? *

Yes Maybe No
How did you come across the Honours Programme Study Association Extensus? *
I would like to subscribe to Extensus' Newsletter to receive the latest updates regarding social, academic and professional events.

Yes, but I would like to use a different email for that. Yes, kindly use the same email address.
Email for Newsletter
example@example.com
Should be Empty:

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If you have any questions or if you want to deregister, please send an e-mail to secretary@extensus.org.

Personal Information

Academic Information

Payment Details

Additional