Brussels Labour

Please print this off for mailing (click the button 'Print Version' below for a simple format), or copy it into your programme for e-mailing, and return to:

Sarah Millar at secretary@brusselslabour.org

First Name..................................................................Surname.................................................................................

Home address............................................................................................................................................................

Mailing address (for members working in the EU institutions we prefer to use your office address) ....................

....................................................................................................................................................................................

Telephone (work) .............................................. (home) ............................................. Fax .......................................

Email (we use email whenever possible)......................................................................................................................

Areas of policy expertise or interest..........................................................................................................................

Labour Party membership (you do not have to be a Party member to join Brussels Labour, but only members of Labour International can take part in some Branch decisions). (Delete as appropriate):

- I am a member of Labour International YES/NO Membership number:

- I am a member of .............................. Constituency Labour Party in the UK YES/NO Membership number:

- I am not a Party member but would like to join: please send me details YES/NO

I wish to join/ renew my membership to the Brussels Labour International Branch
What it costs (this is in addition to your Labour Party subscription)(please tick): Standard rate 25 euros......... Reduced rate (stagiaires, unwaged, retired) 5 euros........ Couples with one unwaged partner 43.75 euros..............

Payment method (delete as appropriate):

- I have completed and returned the attached standing order form for ...........euros to my bank
OR- I have made a transfer of ............... euros to the Branch account 001-1128765-52 (Fortis)
from my account no.................................(please put your name and '2003 subs' in the 'communication' )
OR- I enclose a cheque for........... euros

Signed...................................................................................................Date............................................................

$.............................................................................................................................................................................$
VIREMENT AUTOMATIQUE / STANDING ORDER
(NB: PLEASE GIVE THIS FORM TO YOUR BANK)
MONTANT: 25 euros / 43.75 euros / 5 euros (rayer la mention inutile)
EXECUTION: ANNUELLE du...................................jusqu'à nouvel ordre
COMPTE DONNEUR D'ORDRE: ..........................................................................................................................
NOM.......................................................ADRESSE.................................................................................................

COMPTE BENEFICIAIRE: 001-1128765-52 (Fortis) Brussels Labour, 13 Ave. de la Porte de Hal, 1060 Brussels COMMUNICATION: MEMBERSHIP SUBS

Je, soussigné(e),..............................................autorise ma banque d'effectuer l'ordre permanent susmentionné

Signature...................................................................................................Date............................................................