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Membership and Support Form

Mr. checkbox     Ms./Mrs./Miss checkbox     Association or Organisation  checkbox

Family or organisation name (Capital letters): ___________________________

First name: _______________________________  Date of birth: ____/____/____ 

Profession or field of work:______________________________________________

Address: _________________________________________________________________

Postal Code: _________________________ City/Town: ________________________ 

Country: _____________________________  E-mail: __________________________

Telephone: ___________________________  Fax: _____________________________  

* I would like to join the Caravan association and am hereby sending my
  payment for 2000/2001
  checkbox 30 US$  (for people from "developing" end "emerging" countries,
             students, unemployed people)
  checkbox 60 US$  (for working or retired people from industrialised countries)

* I would like to contribute to the publication of Caravan in 2000/2001 by
  checkbox 15 US$       checkbox 30 US$       checkbox 45 US$       checkbox Other: _____US$

Payment made by: 

checkbox bank or postal cheque, in French Francs or Euros, made payable to 
  "Association Caravane". (for France only)
checkbox direct payment to the association's account: CCP, 45900 La Source,
  France: N° 20041 / 01012 / 4542629F033 / 64 
checkbox credit card (number): ____________________________________

  Holder's name: _________________________________________________________

  Expiry date: _______________  Signature: _______________________________

Please return this coupon with payment to the following address:
Association Caravane, 99 rue Louis Bectard, 77360 Vaires sur Marne, France

© 2001 Alianza para un mundo responsable, plural y solidario. Todos los derechos reservados. Ultima actualizacion, 23 de abril de 2001.