Culturelink Membership Application and Subscription Form


Please enter/renew my/our membership in Culturelink, the Network of Networks for Research and Cooperation in Cultural Development, with the annual contribution for (please check the appropriate)

( ) individuals   -   20  or US $  25  
( ) institutions  -   50  or US $  70  
( ) benefactors -  100 or US $ 135

Name:________________________________________________________________

Institution:____________________________________________________________

Address:______________________________________________________________

_____________________________________________________________________

Phone:__________________________ Fax:_________________________________

E-mail:__________________________ WWW:_______________________________

Date:___________________________ Signature:____________________________

Possible ways of payment are by check, bank account or credit card:

( ) cheque made out to:

IRMO/CULTURELINK
Ul. Lj. F. Vukotinovica 2
P.O. Box 303
10000 Zagreb
Croatia

( ) bank transfer to:

ZAGREBACKA BANKA D.D.
Paromlinska 2
10000 Zagreb
Croatia

Account Holder: Institute for Development and International Relations (IRMO)
Account No.: 1101400944
Bank Sort Code: 3234495
BIC or SWIFT code: ZABAHR2X
IBAN: HR4823600001101400944

( ) credit card:

( ) American Express        ( ) Diners Club        ( ) Visa

Name:_________________________________________

Address:_______________________________________

City:____________________ Postal Code:___________

Country:_______________________________________

Card No.:______________________________________
(please include your card control number, i.e. the last three digits
of your card number at the back of the card)

Card Expiry Date: _________ Signature: ____________


Please print out this form, fill it in and send it to:

IRMO/CULTURELINK
Ul. Lj. F. Vukotinovica 2
P.O. Box 303
10000 Zagreb
Croatia



tel: (+385 1) 48 77 460
fax: (+385 1) 48 28 361
e-mail: Culturelink@irmo.hr



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