Numιro dadhιrent : For use by the association
LES AMIS DU CANAL DU NIVERNAIS Numιro
dadhιrent :
--------------------------------------------------------------------------------------------------------------------------------------
Membership application/renewal for the year
2007
Surname Mr/Mrs/Ms :
. Forename :
. Date of Birth :
.
Surname Mr/Mrs/Ms :
. Forename :
. Date of Birth :
.
Address :
..
Postcode :
..
Country :
.
Nationality :
..
.
Tel :
. Tel Mobile :
. Fax :
..
Email :
. Website :
..
If you own a boat :
-
Boat name :
...
..
Length :
Beam :
.
. Year of
construction :
..
Amount of your subscription :
Individual 18 [ ] - Couple 25 [
] Supporter* 40 [ ] - Benefactor* 50 or + [ ]
*For subscriptions from
Supporters or Benefactors : For one person, tick this box [ ]
For 2 persons (couple), tick this box [ ]
Method of payment : Cheque [
] Cheque No. :
Date :
..
Send payment and completed form to :
-
Claudine RAMEAU, 30 Route Nationale 6 ,
89290 CHAMPS SUR YONNE, FRANCE
Numιro dadhιrent : For use by the association
LES AMIS DU CANAL DU NIVERNAIS Numιro dadhιrent :
-------------------------------------------------------------------------------------------------------------------------------------
Membership application/renewal for the year
2007
Surname Mr/Mrs/Ms :
. Forename :
. Date of Birth :
.
Surname Mr/Mrs/Ms :
. Forename :
. Date of Birth :
.
Address :
..
Postcode :
..
Country :
.
Nationality :
..
.
Tel :
. Tel Mobile :
. Fax :
..
Email :
. Website :
..
If you own a boat :
-
Boat name :
...
..
Length :
Beam :
.
. Year of construction :
..
Amount of your subscription :
Individual 18 [ ] - Couple 25 [
] Supporter* 40 [ ] - Benefactor* 50 or + [ ]
*For subscriptions from
Supporters or Benefactors : For one person, tick this box [ ]
For 2 persons (couple), tick this box [ ]
Method of payment : Cheque [
] Cheque No. :
Date :
..
Send payment and completed form to :
-
Claudine RAMEAU, 30 Route Nationale 6 ,
89290 CHAMPS SUR YONNE, FRANCE