Max Ehrlich
Association		      
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Inscription Form for the
Max Ehrlich Association

Please check the items that apply and fill in the forms below:
 
 
Individual, non-profit institution, school/university or theater group:
      SFr 50 or $30 per year

 Other group or collective member:
      SFr 500 or $300 per year

 Benefactors and sponsoring members:
      SFr 5000 or $3000 per year
 

I/We hereby confirm that I/we support the aims of the Max Ehrlich Association as laid
     down in the statutes. As a member, I/we will receive regular information on activities
     and invitations to events.
Name
Title, profession
Organization or firm,etc.
Address
E-mail
Phone

 

We wish to pay our annual dues by:

Bank transfer

      Banque Privée Edmond de Rothschild S.A.
      Account No. 304.424
      18, rue de Hesse
      1204 Geneva, Switzerland

Visa Credit card
American Express Credit card

     
Credit card number  
Expiration date  
Card owner  
Address
("same" if same as above)		  
     

 

                                 Send mail to info@max-ehrlich.org with questions or comments about the Max Ehrlich Association or this web site.            
                                 Copyright © 2000, 2008 Max Ehrlich Association
                                 Last modified: January 5th 2012