Phood Farm Shop Member Form – Phood Community Farm

1. Subscription details

2. Account information

3. Checkout

You pay

€ 120.00 / year

Aantal personen

Timeslot ophalen

Totaal nu te betalen

Controleer je gegevens

Ga terug om aan te passen

Contactgegevens

E-mail:

Telefoon:

Voornaam:

Achternaam:

Factuuradres

Straat:

Huisnummer:

Toevoeging:

Postcode:

Woonplaats:

Opmerking

Opmerking:

Betaalmethode:

Betaal veilig met je IBAN rekeningnummer of Credit card via Stripe Checkout

Betaal met je bankpas via Ideal

Akkoord automatische incasso:

Hierbij geef ik akkoord om mijn abonnement per automatische incasso te incasseren.

Price:

€120

First Name: First Name Required

Last Name: Last Name Required

Address Line 1:* Address Line 1 is Required

Address Line 2: Address Line 2 is not valid

City:* City is Required

Country:* Country is Required

State/Province:* State/Province is Required

Zip/Postal Code:* Zip/Postal Code is Required

Telefoon: Telefoon is not valid

Phoodbox address housenumber: Phoodbox address housenumber is not valid

Ik heb

User Comment: User Comment is not valid

Email:* Invalid Email

Password:* Invalid Password

Password Confirmation:* Wachtwoordbevestiging komt niet overeen

Stripe Payments

Pay with your Credit Card via Stripe Checkout

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Ik heb de gebruikersvoorwaarden en het privacy-beleid gelezen en ga hiermee akkoord.*

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