TITLE ...........................................................

SURNAME....................................................

FORENAME..................................................

ADDRESS (to which all correspondence should be sent)
............................................................................................................................................

TEL.NO.(Business)......................................

FAX NO...........................................................

E-Mail.............................................................
 

I whish to become a member of the Association Internationale 'Dimitri Chostakovitch' as :
 

- Normal member (subscription costs 25 euros per year - from date to date)

- Supporting Member (subscription from 26 euros to 75 euros)

- Corporate Member (75 euros per year)

- Benefactor (75 euros and more)
 

Date ......................................Signature...............................