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Office Address: Avenue d'Auderghem 199 Brussels 1040 Tel: +32.2.646 3202 Fax:+32.2.646 3202 Mobile: +32(0)494 721934              +32(0)479 701106 E-mail: [email protected] Website: www.puja-brussels.org. Membership application Form. Membership: Individual/Family.

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Office address

Office Address:

Avenue d'Auderghem 199Brussels 1040Tel: +32.2.646 3202Fax:+32.2.646 3202Mobile: +32(0)494 721934             +32(0)479 701106

E-mail: [email protected]

Website: www.puja-brussels.org

Membership application Form

Membership: Individual/Family

For Family only: Number of family members

Mr./Mrs./Miss

Name:

Address:

Address1:

Tel./Mobile:

E-mail:

Proposed by (should be registered member):

Name:

Registration No.

Date of Registration:

Registration valid till:

Family

Individual

Membership Fees paid:

10

25

“I do agree with the objectives of the organization and believe that I also fulfill the criteria of the membership set by the organization. As a member, I will abide with

all directives, regulations and by-laws of the constitution.”

Name & Signature of the applicant:

Date: Place:

Signature of the member who proposed:

Date: Place:

For official use only

Approved by (at least 3 out of 5 Executive Members): Name and signature

1.

2.

3.

Assigned Membership Number

If refused, mention the proposed date to place the application to the General Assembly.

Proposed date:


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