MEMBERSHIP APPLICATION FORM

To become a "Member" of the "Agence de Coopération pour l'Europe de la Mer" please fill in "enter" this form. We will make allowance for your membership when the membership fee will be received.

* essential mentions

I the undersigned hereby declare my wish to become a member of the "Agence de Coopération pour l'Europe de la Mer".

I enclose, together with this declaration, the membership fee (tick the appropriate box*)

2 000 € College 1 - Local and regional authorities.
400 € College 2 - SMI/SMEs as defined by the European Commission.
1 000 € College 2 - Companies with more than 500 employees.
1 000 € College 3 - University, research centres, institute.

And I commit to send it within 15 days following the inscription, to the address hereafter (if by cheque):

METHODS OF PAYMENT*:

By cheque or postal order made out to ACEM.
Send to:
Parc Technologique de Soye
2 rue Dupuy de Lome
56275 PLOEMEUR
FRANCE

By bank transfer (We will send you the conditions by e-mails)

I would like to receive publications in French English

Done in , on

Details
Society :
Fonction/Position :
*Prénom/Name:
*Nom/Surname :
*Adresse/Address :
*Code postale/Post code:
*Ville/City :
*Etat/State :
Téléphone/Phone :
Fax :
*E-mail :
*Confirm E-mail :
*Could you confirm the college :	College 1 College 2 College 3
Envoyer/Enter
Effacer/Erase

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