Membership form

Surname :

First name:

Date of birth :

Address:

Land line phone number : ..............................

Mobile phone number: ..............................

Email:.....................................................

Would like to join the Comhaltas's Patrick Sarsfield branch as:

Date..........................

SIGNATURE

Send back the bulletin to the following postal address , to Anne-Marie O'Connell:

Appt 38

18 rue BAYARD-31000 Toulouse

Join a cheque addressed to "An Comhaltas- Branche Patrick Sarsfield"