Print this form

Member form 2006

Name (Last, First): ___________________________________________

Affiliated group (Association , etc.) : ______________________________

Mailng adress : ______________________________________________
__________________________________________________________
__________________________________________________________

Email adress: _______________________________________________


I promise to adhere to the principles outlined in the Charter of Eau Vive.
I will do my part, as a member of Eau Vive, to fulfill the objectives in its statutes.
I will engage in the promotion of the association and its values.

[ ] I wish to receive documentation about the organization.

Date, place and signature

You will find attached a payment of my contribution for the year for the sum of:

20 euros member contribution
50 euros member contribution
100 euros member contribution

Sent to
Eau Vive, 4 rue Victor Beausse. 93100 Montreuil, France

Print this form

In accordance with the law of January 6, 1978, the information requested is necessary for the processing of your donation by our services and is for the exclusive use of Eau Vive. By writing to our headquarters, you can request that this information be modified or deleted.