APPLICATION FORM

Print, complete and send to the Treasurer:

Christian PERBAL
rue des Peupliers 7
B-6700 Arlon
Cperbal@hotmail.com

The undersigned ,

Last Name :

First Name :

Address :

Date of Birth (D/M/Y) :

Occupation :

Telephone :

E-mail :

Main interest in modelling :

Requests to join IPMS Belgium and transfers his/her annual subscription fee to the bank account n 210-0251354-79 of IPMS Belgium in B-1180 Bruxelles.

IBAN : BE58 2100 2513 5479
BIC : GEBABEBB.

subscription fee:

Payment can also be made by International Money Order sent to the Treasurer (see above)

 

I wish to receive my publications in: o indépendant o du club de: ...............................................

Date:

Signature: