All Correspondence concerning Pertalian matters should be sent only to the official Pertalian headquarters:

To become a member, please print and fill in the form below.

Please include the membership cheque when mailing in the completed form.

Thank you!

        PERTALIAN FRANCE-MALAISIE MEMBERSHIP YEAR 2003

Surname(Nom):................................................................................................

Name(Prenom):................................................................................................

Address:..........................................................................................................

Postcode:........................................................................................................

Country:..........................................................................................................

Telephone:.......................................................................................................

Fax:................................................................................................................

E-Mail:............................................................................................................

Nationality:.....................................................................................................

Date of birth(optional):.....................................................................................

Profession:.......................................................................................................

If applying for family membership:

Spouse's name:.......................................................................... ......................

Spouse's nationality:.........................................................................................

Names of children:..........................................................................................

Date of birth:...................................................................................................

I / We wish to apply for as membership Annual subscription

[______] an individual ordinary member 17 Euros p.a

[______] an ordinary member & spouse 23 Euros p.a

[______] ordinary member & spouse and children 31 Euro p.a  (spouses and children will have the status of family members)

[______] Corporate member or Corporate Sponsor begin from 95 Euros onwards.

I / We enclose a bank/postal cheque of.....................................Euros(payable to Pertalian France-Malaisie) for one year as subscription for year 2003.


Signature of applicant:.........................................................................

Date:..................................................................................................................

**Expulsion - Membership will cease upon resignation
-death or dissolution
-Expulsion is at sole discretion of the Executive Committee and will result from the non-payment of dues or for any serious infraction of PERTALIAN's bylaws.

We do not emulate, We initiate.

          Respect, Integrity, Honor and Professional Ethics