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Franz-Wüllner-Strasse 39
81247 München
Tel.: 089 / 82088925
E-Mail: hwv@mobilfunkkritik.com
Internet: www.mobilfunkkritik.com

By completing this registration form and remitting 250 Euro to the HWV trustee
account you will become a participant in the
Help for Wireless Victims program.
Form Example
Title Dr., Mr, Mrs...
Last name Smith
First name John
House name or
number and street name
15 Sample Street
Country Post code/ZIP code UK-X1 2YZ
City Sample Town
Date of Birth 12.12.1970
Email john.smith@aol.com
Evening phone number (with country-code) 02341/37912
Daytime phone number (with country-code) 030/34756
Fax (with country-code) 0234/47343
Comments: Your personal comments
Are you a pet? ("Yes" or "No") Yes/No

I am transferring the participant fee of 250 Euro into the following trustee account:
Kontoinhaber: Reiner Lang - Rechtsanwalt
Konto-Nr.: 1000101285 Stadtsparkasse
Bankleitzahl (BLZ): 701 500 00 München
Verwendungszweck: EMR-IP/H W V
IBAN: DE 82 70150000 1000101285
BIC: SSKMDEMM
This payment constitutes my enrollment in the Help for Wireless Victims Initiative program. With my signature,
I authorize that my personal and medical data may be used within the framework of HWV.
The enrollment fee is one-time and entitles me to all diagnoses, treatments and other information related to my health issues.
I may opt out of the HWV program at any time. Due to the inclusive nature of the HWV program.
I have read all the statements pertaining to the HWV program and agree with the terms and protocols.


Place                   Date                    Signature

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