Nostitzstr.
36, 10961 Berlin, Germany, Tel/Fax: + 49 - (0) 30 - 21 99 77 93
Membership
Application
I
would like to become a member of the International B. Traven Society.
Surname:
First
name:
Employment:
Telephone/Fax:
E-mail:
Street
address:
City:
Country:
Date:
Signature:
Annual
dues are € 20.00 for students and unemployed individuals, € 35.00 for
employed individuals, and € 70.00 for institutions and patrons. Dues are
payable on February 1 of each year.
Bank
information: Postbank Berlin (bank routing code: 100 100 10), account no. 470
661 103
Authorization
for Direct Debit
I hereby
authorize the B. Traven Society (registered association) Berlin, to directly
debit my account no. _________________ at (exact name of bank)
_________________________, bank routing code: _____________, for payment of
annual dues in the amount of €________.
Should
the account balance not cover the required sum, the credit institute shall not
be obligated to effect payment.
This
direct debit authorization may be withdrawn at any time.
First
name:
City:
Date:
Signature:
© 2005; Internationale B. Traven Gesellschaft e.V.