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
Silver €500
?
Gold €1500
?
Diamond €3000
?

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 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