Modulo di iscrizione OEP

Dati Personali/Personal information:
Cognome/Surname  ______________________________________
Nome/Name  ___________________________________________
Indirizzo/Home address  _________________________________________
Cap/Zip Code  __________________
Città/City  _____________________
Provincia/Province  ______________
Paese/Country  _________________


Dati Professionali/Business Information:
Telefono/Phone  ___________ / ____________________
Professione/Occupation  ______________________________________
Ragione Sociale/Office name  __________________________________
Indirizzo/Office address  _________________________________________
Cap/Zip Code  __________________
Città/City  ___________________
Provincia/Province  ______________
Paese/Country  _________________
Partita IVA/VAT number  __________________________
Telefono/Phone  ___________ / ____________________
Fax/Fax Number  __________ / ____________________
E-mail  _________________________________________


Membership:
  __  Prima Adesione/First Appliance (200,oo EURO)
  __  Sostenitore/Associate (200,oo EURO)
  __  Rinnovo/Renewal
  __  Allego assegno
  __  Mailing List



Firma/Signature  __________________________



Spedire a/Mail to: EUROPEAN ACADEMY OF SPORTS VISION - VIA PARINI,9 48015 CERVIA (RA) ITALY