AAPN - SCHEDA DI REGISTRAZIONE

Per diventare membro dell'Associazione Ambientalisti Per il Nucleare
per favore compilate in stampatello o a macchina e inviate per posta questa scheda di registrazione al seguente indirizzo:

Associazione Ambientalisti Per il Nucleare
55 rue Victor Hugo, F-78800 Houilles, Francia
Tel: +33 1 30 86 00 33 - Fax: +33 9 55 29 00 22
E-mail: it[at]ecolo.org (spam prevention: replace [at] by @) -

Cognome* :

Nome* :

Indirizzo* :

C.A.P.* :

Citt�* :

Paese* :

E-mail* :

Telefono :

Fax :

Professione :

Et� :

anni

(*) Zona richiesta 

Per favore registrate la mia adesione nella categoria seguente:

Membro di sostegno : Approvo la vostra azione (Gratuite, trasmetta a AAPN dal fax)
 Membro Simpatizzante : 25 Euros per un anno
Membro Attivo : 50 Euros per un anno
Membro Donatore : 100 Euros per un anno

S�, acconsento ad essere un corrispondente locale di AAPN nelle seguenti zone : .
Donazione aggiuntiva indipendente dall'adesione per sostenere la vostra attivit� : Euros

Importo totale allegato: EUROS, pagato tramite:
carta di credito ; assegno ; bonifico bancario
all'ordine di : "Ambientalisti Per il Nucleare"
 

 

 

Data : Firma :

 To sign, you can sign the printed paper version if you print this page on paper (in this case please send it by fax or mail), or please type into the"signature" zone your name or any alpha-numerical code legally representing your signature, for example : /John Smith/ or /jsmith8492xfp8902/ if this page is transmitted electronically.

 

PRIMO PUNTO: stampi e trasmetta questa pagina completata

 

This page should be printed and sent by fax to +33 9 55 29 00 22 or by e-mail as a PDF file (if you pay by credit card or electronic wire transfer) or by postal mail (with the cheque, if you pay by cheque). By clicking on the "PRINT" button, you will print this page. You can also use the "Print" button in the menu of your navigating software

 

 

SECONDO PUNTO: trasmetta il vostro pagamento da uno dei tre metodi seguenti

Payment by credit card (in Euros): click on the visa card logo below (choose your currency), 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. Do not send your credit card number by fax to AAPN, please make the payment yourself as indicated by clicking on the visa card icon below. 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 this membership registration form to AAPN by fax or e-mail, and send an e-mail to nuc-it[at]ecolo.org (spam prevention: replace [at] by @) asking for instructions concerning payment by bank to bank transfer. You will receive instructions by e-mail.

Payment by cheque (in Euros): send this membership registration form to AAPN 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.