2018 – HEALTHY HABITS CAMPAIGN APPLICATION FORM – choose from among the 4 options listed below (mark with X) OPTION 1 OPTION 2 OPTION 3 OPTION 4 Activity tracker Bicycle helmet Bathroom scale Blood pressure monitor APPLICANT DATA (please use capital letters and numbers easy to read ) Name Address Birth date Bank name Bank account: SWIFT/BIC code Bank account: IBAN number Your company Employment date Declaration of Consent To be filed together with this application In some countries, there might be unavoidable expenses that the Employee Foundation cannot cover on behalf of our employees, e.g. bank fees and tax. This means that the final amount paid out might be less than EUR 50.