Membership application form

Title
 
First name
 
Last name
 
Address
 
Postcode
 
City
 
Country
 
Telephone
 
Email
Date of birth (optional)
Please make my donation anonymous.
Levels of membership
Diamond €3000
?
Gold €1500
?
Silver €500
?

AND/OR

I would like to make a donation (and benefit from a tax reduction of 45%)
Donation of (€)
Bank details: BE25 6790 0495 5282 / BIC PCHQBEBB
In the communication box, enter “Maecenas Circle” and your name (Please make a separate payment for a donation, entering “donation” in the communication box)

If you wish to pay through a company, please use the bank account of the company and send us the contact details and the vat number in order to receive an invoice

Name of company
Address
Postcode
City
Country
Telephone
VTA number