FAMILIEKUNDE VLAANDEREN vzw

Seat: Van Heybeeckstraat 3 B-2170 Merksem

Companynumber: 0410941587 Bankaccount.: BE95 0682 5054 4458

URL: E-mail:Personal code:……………………………………

(reserved to the projectleader)

DNA BENELUX PROJECTSUBSCRIPTION FORM FOR EXTERNAL PARTICIPANTS(those who already participated elsewhere in a DNA project)

CONDITIONS OF PARTICIPATION: (ticking of all items obliged)

□I am male, attained majority, have legal capacity and wish to be incorporated in the Benelux Project and join a copy of my certificates with at least 37 markers with determination of the haplotype and the subhaplogroup, and also the name of the organization that executed my DNA analysis

□I agree with the insertion of myresults in the databank of the DNA-lab and in the one of the

organizer, where theywill only be accessiblewith mypersonal code and password

□Isendthe organizerwithin 8 daysaGEDCOM-filewith mymale descent of thepaternal line

going back to at least before 1800 (filename: YOURNAME.GED generatedbya genealogical

program) of your(tick):□ full pedigreeor□ patrilineal lineage

□I agree with the publicationof my resultsand patrilineal lineage in a book and/or on cd-rom by the organizer, where I choose as proband (starting person) (tick):

□ myself□ myfather□ my grand-father□ mygreatgrand-father

□I oblige myself to follow the actual news via the website to correspond via e-mail or website and to communicate any change of address, telephone or e-mail tothe organizer

□Itransferwithin 8 daysthe amount of€ 25tobankaccountIBAN: BE95 0682 5054 4458 and BIC: GKCCBEBB ofFamiliekunde Vlaanderen vzw, Van Heybeeckstraat 3 B-2170Merksem-Antwerpen(Belgium) mentioning “DNA Benelux Project external participant” andyour name as participant

□Ideclareto have read and understood the privacy policy and conditions of participationof the project (see website)and to agree unconditionally: (write belowwith your own hand: agreed)

………………………………Date: ………………….Signature: ……………………………………………………………………

PERSONAL DATA(obliged to fill inBLOCKLETTERS):

SurnameandChristian names: …………………………………………………………………………… birthdate:…………………………………………

Address:…………………………………………………………………………………………………… birthplace:……………………………………………………

Postal code: …………………… Commune: ………………………………………………………………… Country: ………………………………………

e-mail: …………………………………………………………………………………………………………………telephone: ………………………………………

member of:□ Genealogical association(s): ………………………………………………………………………………………………………………

□ Local History association(s): …………………………………………………………………………………………………………………………………………

- Sendthisoriginal form to projectmanagerMarc Van den Cloot, Frederik Peltzerstraat 21, B-2500 Lier, Belgium

- Make a copy for yourself, to avoid loss of mail, and send via e-mail ascanof this form together with thegedcomfile

of yourpedigree/patrilineal lineagetoprojectmanager:

□ I wish to use my rightto a discount at the purchase of one (or more) book(s), and/or cd-rom(s)