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Individual Member Application Form

Individual member
Individual member without income (persons over 65 / students / jobless)

Courtesy Title:

Name:

First:	Examples First Name: John, Jacques, Bill
Last:	Examples Family Name/Surname: Brown, Chirac, Gates

Gender:

Male

Female

Description/Speciality:

Main Contact Language:

English

German

French

Private Address:

Street:
City:
State:
Postal Code:
Country:
Default contact address(or; specify company address as default contact address below)

eMail:

Main:
eMail 2:
eMail 3:

Tel.:

Direct:
Private:

Please use International Format (ie.. +41 1 222 ... )

Cellular phone:

Main:
Other:

Please use International Format (ie.. +41 1 222 ... )

Fax:

Main:
Private:

Please use International Format (ie.. +41 1 222 ... )

Other Languages:

2 Letter language codes. (click here for a listing)

Academic Info:

Web:

Personal Web Site

Interests:

Company Information

Company Name:

Description:

Position/Title at Company:

Address:

Street:
Postal address:
City:
State:
Postal code:
Country:
Default contact address (or; specify private address as default contact address above)

Web Site:

URL 1:
URL 2:

Email:

Tel.:

1:
2:
3:

Please use International Format (ie.. +41 1 222 ... )

Fax:

1:
2:

Please use International Format (ie.. +41 1 222 ... )

The annual membership fees are given in the statutes,
There is no initial/registration fee:

CHF 150.- individual members (approx. USD 100.-)
CHF 30.- individual members without income (approx. USD 20.-)
(persons over 65 / students / jobless)

I have read and accept the statutes of the APTE Association and would like to apply for membership.