PRINT OR COPY THIS FORM TO BECOME A MEMBER OF THE CAPUCINE ASSOCIATION.

Join us and help the children !

LAST NAME :_____________________________ .

First name :____________________________ .

Organization :_____________________________________________________ .

Complete postal address :_____________________________________________

___________________________________________________________________ .

Phone :___________________. Fax :___________________________.

E-mail :__________________________________.




I WANT TO :

- become a member (1) * the donation for 2001 is : $ 42 (250 F).

or

- become a great member (1) * donation for 2001 is : $ 85 or more (500 F or more).

(1) Cross out if you don't choose it.




Send your donation by check only to :
ASSOCIATION CAPUCINE .

ADDRESS : ASSOCIATION CAPUCINE - 5 , Pigeau Sud - 33620 - MARCENAIS. FRANCE.

Thanks a lot for your donation and for the children.
Web membership form printed on :
www.ifrance.com/capucine/anglais.html