Family Name..................................................................................................... First Name......................................................................................................... Address............................................................................................................ Postcode.......................................................................................................... Town................................................................................................................ Country............................................................................................................ Telephone......................................................................................................... Fax................................................................................................................... E-mail............................................................................................................... Website............................................................................................................. I wish to financially support the humanistic project and become a citizen of the Brotherhood Boat: □ By cheque Pay to the order of the Brotherhood Boat, send mail to: Association Le Bateau pédagogique 7 bis, rue Jacques-Cartier 44300 Nantes France □ By transfer
Bank Code: ........................................................................................................ Filial Code: .......................................................................................................... Amount: .............................................................................................................. Bank account number: .......................................................................................... Bank: .................................................................................................................. Agency: ............................................................................................................... International identification: ................................................ □ Via PayPal □ Other (to be specified): ....................................................................................... I give: □ 1 € Contribution □ I authorize the association to use my name for all of the necessary promotion forms for the development of the Brotherhood Boat project. Date and signature: |
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