Registration form

Course*

Title*

Surname (Maiden name)*

First name*

Social Security number*

Name of spouse

Date of birth*

Place of birth*

Country of birth*

Nationality*

Profession

Address (street and number)*

Postal code*

Locality*

Country*

Other country*

Email*

Phone 1*

Phone 2

Do you have a voucher from ADEM, ONIS or MIFA*

No, I do not have a voucher
Yes, I have a voucher from ADEM or ONIS
Yes, I have a voucher from MIFA

ADEM or ONIS voucher number*

MIFA voucher number*

Photo/scan of the voucher*

Drop files here or

ATTENTION: for a validated registration you are obliged to send the original voucher within eight days by post to Moien asbl, 2, rue Batty Weber L-3493 Dudelange

Enter the code of the course that you currently participate in

You need to send us a copy of the voucher to moienasbl@pt.lu as soon as possible.

Administrative fee*

Price: 10,00 €

Total

0,00 €

Email

This field is for validation purposes and should be left unchanged.

Nos cours

Contact