| EAHIL AFFILIATED membership application form AFFILIATED MEMBERSHIP APPLICATION at annual fee of: EUR 397 (2008) Family name: ……………………………………………………………………………
First name: ……...………………………………………………………………………
Institutional address | Institute/Company: ………………………………………………………………………………… Address: …...…………………………………………………………………………….…
City code: ………………………………… City:…………………………… …………
Country: ...………………………… ………………………………………………………
Telephone …………...………………………………………………………………………
Fax: ……………………………………………..………………………………………………
E-mail: …...…………………………………………………………………………………… | Home address | Home address: ……….….………………………………………………………………… City code: ………………………… ……………City: ……………………………………
Country: ………………………………………………………………………….….…………
| | On which address do you prefer to receive the Journal of EAHIL? | ( ) Company address
( ) Home address | | On which address do you prefer to receive the membership invoices? | ( ) Company address
( ) Home address | | ( ) I would like to receive an invoice | ( ) I will use the card payment form properly filled in with all details and undersigned, which will reach you by fax, e-mail or mail within 14 days | | ( ) I am interested in advertisements in the Journal of EAHIL and will contact the Secretariat on this via EAHIL@nic.surfnet.nl | ( ) I am interested to receive quarterly self-adhesive address labels for mailing promotional material of my company to EAHIL members (EUR 150 extra/year) | Membership in other associations?: …………………..…………………………..……… See statutes for definition of membership
Signature: …………………………………………………………………….. Position: …………………………………………………………………….... Date: …………………………………………………………………………....
Send the membership application form to:
EAHIL Secretariat, c/o Leijte & Regoort,
P.O. Box 1388, NL-3600 BJ Maarssen, The Netherlands
fax : +31 346 550 876
| 
