Personal Information Name: ………………………………………………………………………………………….. Organization(*)………………………………………………………………………………… ……………………………………………………………………………….……………….. Date of Birth……………………………………………………………….…………………. Address…………………………………………………………………………….……..…… ……………………………………………………………………………………..…………… ……………………………………………………………………………..…………………… ……………………………….………………………………………………………………… Position title……………………………….……………………………………………………. CP City: ………………………..Country: …………………………………………………….. Tel: …………………………………………………………………………………………..…. Fax: ………………………………………………………………………..…………………… Email: ……………………………………………………………………………………...…… URL: …………………………………………………………………………………………… Name of two members that recommend your membership First member: …………………………………………………………………………...……… Second member: ……………………………………………………………………….......……
ASMDO fees Individuals: ……………………15 Euros Institutions: ……………………200 Euros Students: ………………………10 Euros (please join or fax a copy of your student card) Mode of payment (T) Bank draft payable to “Association ASMDO” Bank transfer to account number 42119802215 of Bank Populaire Bourgogne Franche Comté, Bank code : 10807, Window code: 00002, Rib key : 66. For international transfer: IBAN : FR76 1080 7000 0242 1198 0221 566 SWIFT(BIC) : CCBPFRPPDJN (*) Please provide the organisation name in full. If your organisation is commonly known by an acronym, please include both the acronym and the full name (T) Please fill the appropriate figures and return it to the ASMDO secretariat
ASMDO Institut FEMTO – ST / Dept. LMARC, 24, rue de l’Epitaphe, 25000 Besançon, France www.asmdo.com , E-mail :
[email protected] Tel.: 00 (33) 3 81 66 65 47 or 00 (33) 3 81 66 60 00, Fax: 00 (33) 3 81 66 67 00
