IBC - Membership registration Form

To become a member of the Institute Bruno Comby FILL and PRINT (to paper or PDF file) and SEND this registration form to :

Institute Bruno Comby
55 rue Victor Hugo, 78800 Houilles, France
Phone: +33 1 30 86 00 33 - Fax : + 33 9 55 29 00 22 ; E-mail: ibc-en[at]comby.org (spam prevention: replace [at] by @ in the e-mail)

First name* :

Name* :

Address* :

Zip code* :

City* :

Country* :

E-mail* :

Tel :

Fax :

Profession :

Age :

years

(*) Required zone  

 

Please register or update my membership in the following category :

Supporting member : I approve your action (FREE - send by fax or PDF file)

Sympathizing member : 25 Euros for one year
Active member : 50 Euros for one year
 Donating member : : 100 Euros for one year

Dues-paying members receive a receipt by traditional mail. You will be informed by the mailing list of the IBC. New members are admitted subject to the approval of the Board of Directors.

I agree to be a local correspondent of the IBC in the my area :
Additional donation : Euros to support the IBC's scientific research and activities.

TOTAL : EUROS
paid by (choose) : credit card (paypal) bank to bank transfer cheque
to the order of: Institut Bruno Comby

 

 

Date :    Signature :

 

To sign, you can sign the printed paper version if you print this page on paper (in this case please send it by fax or mai)l, or please type into the"signature" zone your name or any alpha-numerical code legally representing your signature, for example : /John Smith/ or /jsmith8492xfp8902/ if this page is transmitted electronically.

 

FIRST STEP : print and send this completed page

This page should be printed and sent by fax to +33 9 55 29 00 22 or by e-mail as a PDF file (if you pay by credit card or electronic wire transfer) or by postal mail (with the cheque, if you pay by cheque). By clicking on the "PRINT" button, you will print this page. You can also use the "Print" button in the menu of your navigating software.

 

 

SECOND STEP : send your payment by one of the three following methods

Payment by credit card (in Euros): note the amount to be paid, then click on the visa card logo below (choose your currency), type the amount of your membership in the appropriate box and follow the instructions. Most credit cards are accepted (Visa, Mastercard, American Express...). The transmission of your credit card number is securized by https protocol.

Click here: for payment by credit card

Payment by bank-to-bank transfer (in Euros): send this membership registration form to the IBC by fax or e-mail, and send an e-mail to ibc-en[at]comby.org (spam prevention: replace [at] by @ in the e-mail) asking for instructions concerning payment by bank to bank transfer. You will receive instructions by e-mail.

Payment by cheque (in Euros): send this membership registration form to IBC printed on paper by traditional mail with your cheque to: Institut Bruno Comby, 55 rue Victor Hugo, 78800 Houilles, France. Cheques are to be denominated in EUROS and to be drawn on a French bank. If your bank is not in France, ask your banker to prepare a cheque drawn on a French bank. Eurocheques are not accepted.

According to the law, you have the right to access and correct the computerized information which concerns you.