Registration Form

To become a member of the OPTIMISTS' MOVEMENT, FILL, PRINT and RETURN this registration form to :

Optimists' Movement
55 rue Victor Hugo, 78800 Houilles, France
Phone: +33 1 30 86 00 33 - Fax : + 33 9 55 29 00 22 ; E-mail: [email protected]

First name* :

Name* :

Address* :

Zip code* :

City* :

Country* :

E-mail* :

Phone :

Fax :

Profession :

Age :

years

(*) Required zone

Please register or update my membership to the OPTIMISTS' MOVEMENT in the following category :

Supporting OPTIMIST : I approve your action (FREE) -> print and fax this page to +33 9 55 29 00 22

Sympathizing OPTIMIST : 25 Euros (or 25 US $) for one year
Active OPTIMIST : 50 Euros (or 50 US $) for one year
Donating OPTIMIST : 100 Euros (or 100 US $) for one year

You will be informed by the mailing list. Dues-paying members will receive a receipt by traditional mail. New members are subject to acceptation by the Board of Directors of the Optimists' Movement.

I agree to be a local correspondent of the OPTIMISTS in the following area :
Additional donation to support the OPTIMISTS : Euros (or US $)

TOTAL : Euros (or US $), at the order of : OPTIMISTS' MOVEMENT
paid by (choose) : bank to bank transfer credit card cheque
 

 

Date :    Signature :

 

 

_____________________________________________________________________________

To pay by credit card, note the amount of your payment, and click on the small icon just below :

 

Payment by credit card (in US$): 1/ fill out, print (on paper or PDF), and fax the printed paper form to +33 9 55 29 00 22 or e-mail the PDF form to [email protected] - 2/ click on the visa card logo and follow the instructions. Most credit cards are accepted (Visa, Mastercard, American Express...). The amount of your payment will be debited from your credit card account. Do not send your credit card number to the OPTIMISTS', please make the payment yourself as indicated by clicking on the visa card above. The transmission of your credit card number is securized by https protocol.

Payment by cheque (in Euros): fill out, print, and send this membership registration form by traditional mail with your cheque. Cheques are to be denominated in EUROS and to be drawn on a French bank. If your bank is not in France, ask your banker to prepare a cheque drawn on a French bank. Eurocheques are not accepted.

Payment by wire transfer (in Euros): 1/ fill out, print (on paper or PDF), and fax the printed paper form to +33 9 55 29 00 22 or e-mail the PDF form to [email protected] - 2/ send an e-mail to [email protected] and ask for instructions concerning payment by wire transfer. You will receive instructions by e-mail.

According to the law, you have the right to access and correct the computerized information which concerns you.