First Name:

Surname:

Date of Birth:    day/month/year

Nationality:*

Address:

Postal/Zip Code:

City:

Country:

Telephone 1:

Telephone 2:

Fax:*

E-mail:

Education:*

Profession:*

* Optional

You will obtain a personal membership card as soon as your name is registered
as a friend of Les Ballets Persans.

Payment

The membership fee should be sent to:

PlusGirot Bank
Account no: 339507-6
SWIFT code: PGSISESS
International Account Number (IBAN): SE59 9500 0099 6034 0339 5076
BIC: NDEASESS

Date of Payment:   day/month/year

Name of the Bank:

Message:

Security Code *