One-off joining fee CHF 200.—; minimal annual fee CHF 80.—

Declaration of membership please use BLOCK CAPITALS

I hereby enrol as a member of “DIGNITAS – To live with dignity – To die with dignity” and I have read and understood the DIGNITAS information brochure:

□ Male □ Female

First name(s): ………………... …………………………………………………… Surname(s): ………………......................................................................................

Street: .......................................................................................................................

Town and postal code: .............................................................................................

Date of birth: ................................. Place of birth: ...................................................

Profession: ...............................................................................................................

Telephone: Private: ..................................... Business: ...........................................

Fax: Private: ................................................ Business: ...........................................

Mobile Telephone: ...................................... E-mail: ..............................................

Nationality: ..............................................................................................................

For Swiss citizens only: Bü rgerort: …................... AHV-Nr.: |........ |...... |....... |....... | My preferred language: □ ENGLISH □ FRENCH □ GERMAN □ ITALIAN

One-off joining fee CHF 200. —; minimal annual fee CHF 80. —

(payment after receipt of DIGNITAS’ invoice) Date: Signature:

............................................... .......................................... ……….....

What has motivated you to sign up as a member? (voluntary information)

☐ I support DIGNITAS in its endeavours to lift the existing taboos of suicide, enforce patient’s rights, freedom of choice and self-determination during lifetime and at its end.

☐ I witnessed first-hand an excruciatingly painful struggle in dying and would like to prevent this from happening to me.

☐ I suffer from a disease and wish for an accompanied suicide when the time comes.

send to: DIGNITAS, P. O. Box 17, 8127 Forch, Switzerland

Fax: +41 (0)43 366 1079 / E-Mail: dignitas@dignitas. ch

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