Joining Form

I wish to receive Pachacamac's Newsletter/gazette by email (In this case, the mention of your email in the form above is mandatory). The address to send the ...
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Joining Form First Name*: Last Name*: Date of birth:

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Nationality:

Adress*:

Zip code*:

Town*:

State:

Country*:

Phone number:

Mobile Phone:

Email : The fields which include a * mark are mandatory. I wish to join the Pachacamac association. I attach my annual payment of 20 € to my joining form.

The address to send the filled form is the following: Pachacamac 9, rue du Séminaire de Conflans 94220 Charenton Le Pont France Checks must be payable to Pachacamac. I wish to receive Pachacamac's Newsletter/gazette by email (In this case, the mention of your email in the form above is mandatory).

Signature*: