about the acsn

Application Form ACSN
Mr./Miss/Mrs./Ms.
First name: *
Last name *
Occupation	Student Professional
Title
E-mail: *
Phone number:
Street and number: *
City: *
Zip/Postal code: *
Country *
Phone number company/institute
Full address company/institute
Discipline/area of expertise *
Affiliated with company/institute
Contribution *	€ 35,- for members € 17,50 for students € 100,- for companies/entities
Gelieve uw contributie te storten op rekeningnummer ABNAMRO 53.90.38.946 of giro 480700 t.n.v. Studiegenootschap Canada, Houten, onder vermelding van ’nieuw lid’. Uw lidmaatschap vangt aan na ontvangst van de verschuldigde contributie.