LowCountriesSculpture . org 

 

Membership Application Form

Please tick or complete

Title1
Christian Name
Surname
  
Preferred Email
Emergency Tel
(Preferably a mobile number, to be used exclusively just before / during events)
  
Address 1: Home    Office   both   Other 
Institution
Street
Post Code and City
Country
Tel
Fax
Email
Web
  

Address 2:

 Home    Office   both   Other 
Institution
Street
Post Code and City
Country
Tel
Fax
Email
Web

  

Membership categories
 

     

Please choose a method of payment:
Our preferred method of payment is by credit card. If however you or your institution does not have a credit card, please pay by bank transfer.

After submitting this form, I will pay

 

     
I agree my name and email to be added to the List of Members (only accessible to fellow members)

 

  Name:       Yes   No  

  Email:       Yes   No  

How did you get to know about the Society?

What activities would you like us to organise that do not figure on the current programme?

Do you have any specific interests or contacts that you would like us to know?

Would you like us to raise a major issue, such as the problematic conservation of a particular sculpture?

This document will be sent confidentially by encryption (SSL technology) 

 
 

Alternatively, you may print out and send this form to: POBox 1304, B-1000 Brussels 1