BLUES etc… Membership

To become a member of BLUES etc… , print this page and address it to:

Blues etc...
Chez Mr C. JANDIN
1 Allée Maryse BASTIE
95150 - TAVERNY

REQUEST to become a BLUES etc... Member
Type of member

I wish to adhere to BLUES etc as a member

actif
23€
benefactor
50€
donor
unlimited
Postal adress of Member
NAME :
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GIVEN NAME :
.....................................................................................................................................  
ADRESS :
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POSTAL CODE :
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TOWN :
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COUNTRY :
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Phone :
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E-mail :
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Selected mode of payment
Chèque Please herewith find has check off year amount off ........ Euros payable to BLUES etc...
     
Virement Off ..... Euros one the account of BLUES etc... whose references banquaires are as follows:
IBAN : FR76 1820 6000 6656 2561 2900 191
BIC : AGRIFRPP882
    My subscription will be recorded after payment by my bank of the corresponding amount.
Confirmations by mails of the payments by the banks are to be sent to
     
Place of writing .............................................
0n ...................             
Visa



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