(registration slip) for - Penya Barça de Luxembourg

(registration slip) for - Penya Barça de Luxembourg

REGISTRATION FORM
FOR PENYA BARÇA DE LUXEMBOURG
Option:
Individual (18+)
20 € yearly
Individual (minor)
10 € yearly
Family *
30 € yearly
PERSONAL DATA OF THE NEW MEMBER:
First name:………………………………………………………………………………………..
Last name:…………………………………………………………………………………………...
Address:……………………………………………………………………………………………..
Postal code:…………………………. City:……….……………………………………………….
Telephone number:……………………… E-Mail:………………………………………..
Date of birth:……………………………………………………………………………...
If you are a member of F.C. Barcelona tick this box
F.C. Barcelona membership number:………………………………………………………………….
…………………….
Signature of new member:
Send to: (Penya Barça de Luxembourg, 173, Cité Roger Schmitz L-7381 Bofferdange)
By E-mail: [email protected]
* For the family option we need a registration form from each member.
The ordre de virement must be given to the bank or done by ordre permanent via Internet.
__________________________________________________________________________________
ORDRE DE VIREMENT
Mme / Mlle / Mr …………………………………………………………………………………
Titulaire du compte nº :…………………………………………………………………………
Prie la banque ……………………………………………………….. à Luxembourg.
De débiter ANNUELLEMENT mon compte de la somme de 10 EUROS.
De débiter ANNUELLEMENT mon compte de la somme de 20 EUROS.
De débiter ANNUELLEMENT mon compte de la somme de 30 EUROS.
En faveur de la PENYA BARÇA DE LUXEMBOURG au compte BGL
IBAN LU96 0030 3301 6107 0000
Luxembourg, le ………………………………………………………..
Signature