bulletin adhésion

Imprimer

 

                             I                                      

 

Nom :   M.

                                    Mme


Prénom :


Adresse   rue

 

Lieu dit

 

Code postal

 

Ville

 

Téléphone DOMICILE

 

Portable

                              

 

E-MAIL.............................................................@......................................

 

Je souhaite adhérer à l’association ALDAHP  et joins en conséquence un chèque de :

                                              30 €uros(individuel)   ou 50 €uros (couple) à l’ordre de l’ALDAHP

                                                Envoyer bulletin et chèque à   ALDAHP

                                                                                      chez Claude JEAN FRANCOIS

                                                                                            100D cours Lafayette

                                                                                                        69003 LYON

 

                                                                                                                                                                                           

                                                                                                                                       Fait à                            le

                                                                                                                                                         Signature :

 

 

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