Sign Up Form(Required)

First
name_______________________Surname____________________
Address:_______________________________________________
_____________________________________________________
Tel:________________________ Email:______________________
Formulas:(please circle your chosen formula and your payment method)
n 1: 95 ;

n 2: 50 ;

n 3: 15 ;

n4: 35 ;

n 5: 25 .

Please note that payment must be made by 25th August 2015 by one
of the following methods:
1) virement bancaire sur le compte bancaire ouvert la BAMI :
Banque Michel INCHAUSPE, 48 boulevard Victor HUGO, 64500-ST-JEANde-LUZ.
IBAN (International Bank Account Number) FR76 1795 9000 2885 0220
2690 108 BAMYFR22
2) chque bancaire payable en France
3) Virement au compte PAYPAL

I have read, understood and agreed the conditions of the event and I will
comply with them.

SIGNATURE
DATE_______________________2015
Return your completed Sign Up form to :
Hubert KIRSCHHOFFER,
1bis avenue de Montbrun,
64600 Anglet
France

hubert.kirsch@wanadoo.fr