L'Alliance Francaise

Membership dues

Individu - $ 30.00

Famille - $ 50.00

Etudiant - $ 10.00

- none -

BermudaTix fee *

BermudaTix fee - $ 2.00

Optional donation

Total Amount

Name and Address (LF):

Salutation: *

Prenom/First Name *

Nom/Last Name: *

Address: *

Ville/City (Leave blank for Bermuda addresses)

Code postal/Postal Code:

Pays/Country: *

State/Province/Parish: *

Telephone (Home): *

Phone (Work):

Mobile phone:

Credit Card

Card Type

Card Number *

Security Code *

Expiration Date *

My billing address is the same as above

Billing Name and Address

Billing First Name *

Billing Middle Name

Billing Last Name *

Street Address *

City *

Country *

Parish/State/Province *

Postal Code *

Add'l info (LF)

Additional information:

Prenom de l'epoux/Spouse's first name:

Nom/Last name:

Profession:

Nationalite/Nationality:

Nombres d’enfants moins de16 ans/Children under 16

Activite d'interet/Areas of interest:

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