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 |
( ) bank transfer to: |
ZAGREBACKA BANKA D.D. Account Holder: Institute for Development and International Relations (IRMO) |
( ) credit card: |
( ) American Express ( ) Diners Club ( ) Visa Name:_________________________________________ Address:_______________________________________ City:____________________ Postal Code:___________ Country:_______________________________________ Card No.:______________________________________ Card Expiry Date: _________ Signature: ____________ |
Please print out this form, fill it in
and send it to:
IRMO/CULTURELINK |
|
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