Membership application form

1) MEMBERSHIP DETAILS
Please select the preferred membership type
2) PERSONAL DETAILS
3) COMPANY DETAILS
4) BILLING
Every membership is person bound. The membership can however be paid by your current company.
5) PROFILE PICTURE & ID
You have selected the membership with an annual cost of . In case you apply for a membership during the year, you will receive an invoice for the remaining months of this year. On the first of January of the following year your membership will have a standard duration of 1 year unless you have denounced.
By submitting this form I apply for an ADCN membership.
I have read, understood and agree to the terms & conditions
Submit
{"plantype":{"err":"Please, select the membership type","label":"Membership"},"personal_title":{"err":"Please, fill in","label":"Prefix or title"},"personal_fname":{"err":"Please, fill in","label":"First name"},"personal_lname":{"err":"Please, fill in","label":"Last name"},"personal_bdate":{"err":"Please, fill in","label":"Birth date"},"personal_adress":{"err":"Please, fill in","label":"Address"},"personal_pcode":{"err":"Please, fill in","label":"Postal code"},"personal_city":{"err":"Please, fill in","label":"City"},"personal_email":{"err":"Please, fill in","label":"E-mail"},"personal_phone":{"err":"Please, fill in","label":"Phone"},"company_name":{"err":"Please, fill in","label":"Company name"},"company_address":{"err":"Please, fill in","label":"Company address"},"company_pcode":{"err":"Please, fill in","label":"Postal code"},"company_city":{"err":"Please, fill in","label":"City"},"company_phone":{"err":"Please, fill in","label":"Phone"},"company_email":{"err":"Please, fill in","label":"E-mail"},"company_jobtitle":{"err":"Please, fill in","label":"Job title"},"company_industry":{"err":"Please, fill in","label":"Primary industry"},"company_esince":{"err":"Please, fill in","label":"Employed here since"},"whopay":{"err":"Please, select billing type","label":"Billing"},"billing_title":{"err":"Please, fill in","label":"Prefix or title"},"billing_fname":{"err":"Please, fill in","label":"First name"},"billing_lname":{"err":"Please, fill in","label":"Last name"},"billing_adress":{"err":"Please, fill in","label":"Address"},"billing_pcode":{"err":"Please, fill in","label":"Postal code"},"billing_city":{"err":"Please, fill in","label":"City"},"billing_email":{"err":"Please, fill in","label":"E-mail"},"billing_phone":{"err":"Please, fill in","label":"Phone"},"billing_name":{"err":"Please fill in","label":"Naam debiteur"},"billing_iban_number":{"err":"Please fill in","label":"IBAN account number"},"billing_location":{"err":"Please fill in","label":"Location"},"billing_date":{"err":"Please fill in","label":"Date"},"picture_profile":{"err":"Please, upload your profile picture","label":"Profile picture"},"picture_id":{"err":"Please, upload a copy of your ID","label":"Passport or ID card"},"picture_studentcard":{"err":"Please, upload a copy of your student card","label":"Student card"},"filetype_err":"Please, follow the attachment format instructions","checkbox_err":"You have to accept our terms and conditions to proceed","email_format_err":"Please, use the correct data format"}