MEMBERSHIP APPLICATION FORMN

Year 2007
(Valid until December 31, 2007)
NAME OF THE MEMBER

Last Name :

First Name :

Adress :

Country:

Zip code :
City :
Tel (home) :
Tel (office) :
Mobile :
E-mail :
FOR HEALTHCARE PROFESSIONAL :
Thank you, to specify your speciality :__________________________________

(to fill out the incomplete mentions and to replace the incorrect mentions)

PERSONAL DETAILS CONCERNING THE PATIENT

Last name :


First Name :

Birthdate :
Sex :
MEMBERSHIP FEES

(the contributions and gifts profit from article 200-5 of the General Tax) *

Annual Fee:

Please indicate type of membership required :

Parent
Professionnal
Others
30 € 45€
Voluntary Contribution Level (optional):

Your voluntary contribution _______ Euros.

Signature (obligatory) :

Please fill up this form and send with your payment (by bank check or postal) to :
Ariane Association

Tel : 01.42.22.33.21

46, Bd Jean Jaurès
E-mail : fildariane@wanadoo.fr
92110 CLICHY
Correspondance :
This Information is necessary for your membership. They are the subject of a data-processing treatment and are intended to the secretariat of association. Pursuant to article 34 of the law of January 6, 1978, you profit from a right of access and of correction to your concerning information.

* The contribution and/or donation right to reduction only in the general conditions dued to article 200-2 of the General Tax Code are metioned, i.e. if they are carried out "with the profit of individual or organizations of general interest, of nature philanthropic, educational, scientific, social, family or cultural


2006 Charity Ariane
The information contained in this website is intended to inform you and cannot replace any medical opinion or any specific treatment. You must obligatorily consult a qualified doctor before starting any medical treatment.