Application Form Agent Agent Name Applicant Your Name (required) Date of Birth (required) Passport number (required) Address (required) Phone Number (required) e-mail address (required) Next of kin (required) Next of kin telephone number (required) Mother's Christian name (required) Father's Christian name (required) Emergency Contact Emergency Contact Name (required) Emergency Contact Relationship (required) Emergency Contact Phone Number (required) Lead Source (required) BackNext Joint Application Purchaser / Join Application Your Name (required) Date of Birth (required) Passport number (required) Address (required) Phone Number (required) e-mail address (required) Next of kin (required) Next of kin telephone number (required) Emergency Contact Emergency Contact Name (required) Emergency Contact Relationship (required) Emergency Contact Phone Number (required) BackNext Plan Plan: Palmerita 2495€--2495Palmera 3895€--3895Sierra 4295€--4295Laguna 5999€--5999 Payment Type: FullMonthly Instalments Deposit: Please Select--NA500€--5001000€--10001500€--15002000€--2000 Remaining Balance: Payment Term: Monthly Repayments: Direct Debit By signing this mandate form, you authorize (A) Funeral Plans Europe to send instructions to your bank to debit your account and (B) your bank to debit your account in accordance with the instructions from Funeral Plans Europe. This mandate is on ly intended for business-to-business transactions. You are not entitled to a refund from your bank after your account has been debited, but you are entitled to request your bank not to debit your account up until the day on which the payment is due. Please contact your bank for detailed procedures in such a case. Name Address Swift Bic / Sort Code IBAN / Account Number Date Signature Payment Type: FullMonthly Instalments Deposit: Please Select--NA500€--5001000€--10001500€--15002000€--2000 Remaining Balance: Payment Term: Monthly Repayments: Direct Debit By signing this mandate form, you authorize (A) Funeral Plans Europe to send instructions to your bank to debit your account and (B) your bank to debit your account in accordance with the instructions from Funeral Plans Europe. This mandate is on ly intended for business-to-business transactions. You are not entitled to a refund from your bank after your account has been debited, but you are entitled to request your bank not to debit your account up until the day on which the payment is due. Please contact your bank for detailed procedures in such a case. Name Address Swift Bic / Sort Code IBAN / Account Number Date Signature BackNext YOUR DECLARATION YOUR DECLARATION. I hereby agree to purchase a funeral plan from Funeral Plans Europe (SL) NIF B42671487 as specified above. I confirm that I have received and read the key facts which describe the benefits and terms of the plan. On purchasing plan, I accept that my personal details will be held for the purpose of administering the plan and will be shared with relevant individuals and funeral directors in order that the plan can be enacted. Applicant 1 I have read the key facts. Signature: Applicant 2 I have read the key facts. Yes Signature:
