Application form for partners

Application form for partners

You're about to become an important part of it!

Personal Details

First Name (*):

Last Name(s) (*):

ID/TIN (taxpayer number) (*):

Date of Birth (*):

Job :

Telephone Number (*):

email (*):

Province (*):

City/town (*):

Postal Code (*):

St./Av./Blvd. (*):

Name (*):




Door Number:

Membership fee

Exact amount: (*):

On a... (*):

Bank account data (*)

(4 digits):

Banking Institution
(4 digits):

Bank Office
(4 digits):

CD check digits
(2 digits):

Account Number
(10 digits):

(N.B. We will send a receipt to your bank account. You must inform your banking institution beforehand)

Information for partners

What do you wish to be sent? (*):

In which language? (*):

Write the following letters and numbers (this is a security measure):captcha

You are a private individual, is that right? If you are a corporation, this is your application form.

Fields marked with an asterisk are mandatory fields and must be filled out.

This is a secure secured web page (https) . Data transfer is encrypted.

We are an association declared to be of public utility.With the modification of the Tax Law you will be tax-deductible more for your contribution (that applies for the IRPF tax). We will send you a receipt so that you can benefit from this fiscal deduction.

The personal data provided by our sponsors/partners/members shall be treated in accordance with the Organic Law 15/1999 concerning Personal Data Protection, and shall be part of a data file registered in the Spanish Agency for the Protection of Data. The purpose of this data file is exclusively to be able to manage, in an appropriate manner, confidential information belonging to our members and the amount of their donations, as well as to be able to inform them of our activities.

You can exercise your rights to access, change, oppose or delete your data by contacting Medicus Mundi Mediterrània, C/ Secretari Coloma, 112, 1º Edifici Pòdium, 08024 Barcelona, on the phone 93 418 47 62 o sending an email to