AEPN - FORMULAR DE ADEZIUNE

Pentru a deveni membru al "Associatei Ecologistilor Pentru Energia Nucleara",
COMPLETATI, TIPARITI, SEMNATI si trimiteti prin posta acest formular de adeziune pentru a deveni membru AEPN la urmatoarea adresa:

Asociatia ecologistilor pro-nuclear
55 rue Victor Hugo, 78800 Houilles, France
Telefon: +33 1 30 86 00 33 - Fax: +33 9 55 29 00 22 ; E-mail: ro[at]ecolo.org (spam prevention: replace [at] by @)

Prenumele* :

Numele* :

Adresa* :

Codul* :

Localitatea* :

Country* :

E-mail* :

Telefon :

Fax :

Profesia :

Varsta :

years
  (*) Required zone 

Va rog sa ma inregistrati ca membru in urmatoarele categorii:

Supporting Member : I approve your action (FREE - send to AEPN by fax)
 Membru Simpatizant (pe an) : 25 Euros (25 US$)
Membru Activ (pe an) : 50 Euros (50 US$)
Membru Donator (pe an) : 100 Euros (100 US$)

YES, I agree to be a local correspondent of AEPN in the following area :
Donatie suplimentara pentru sprijinirea asociatiei : Euros

Suma Totala: Euros, platit prin :
credit card cec transfer bancar (alegeti)
La dispozitia "Ecologistilor Pentru Energia Nucleara"

 

   Data : Semnatura :  

 

 FIRST STEP : fill out, print and send this page to AEPN

After completing this form, select your printer (or PDF format) and click on the "Print" button to print this page. You can also use the "Print" button in the menu of your navigating software. 

This page can be printed either : 1/ on paper, in this case, fax the paper-printed form to +33 9 55 29 00 22 or 2/ to a PDF file (using ACROBAT WRITER or a similar software), in this case send the PDF file to ro[at]ecolo.org (spam prevention: replace [at] by @).

Sign the printed paper version if you print this page on paper and send it to AEPN by fax, or type your name or any alpha-numerical code legally representing your signature, for example : /John Smith/ or /jsmith8492xfp8902/ into the "signature" zone, if this page is printed to a PDF file and sent to AEPN by e-mail.

 

SECOND STEP : send your payment to AEPN by one of the three following methods

Payment by credit card: note the amount of your membership (indicated above), click on the visa card logo below (choose your currency), type the amount of your membership in the appropriate box and follow the instructions. Most credit cards are accepted (Visa, Mastercard, American Express...). The amount of your payment will be debited from your credit card account. The transmission of your credit card number is securized by https protocol.

click : for payment by credit card in Euros (EUR)

  Payment by wire transfer (in Euros): send an e-mail to ro[at]ecolo.org (spam prevention: replace [at] by @) asking for instructions concerning payment by electronic wire transfer. You will receive instructions by e-mail.

Payment by cheque (in Euros): send this membership registration form printed on paper by traditional mail with your cheque to : Environmentalists For Nuclear Energy, 55 rue Victor Hugo, 78800 Houilles, France. Cheques are to be denominated in EUROS and to be drawn on a French bank. If your bank is not in France, ask your banker to prepare a cheque drawn on a French bank. Eurocheques are not accepted.

According to the law, you have the right to access and correct the computerized information which concerns you.