MEMBERSHIP FORM & INVOICE YEAR 2006 

Please fax this form back to + +49 89 55277299 

PLEASE NOTE THAT THIS INVOICE CAN BE PUT IN YOUR COMPANY ACCOUNT AS PROFESSIONAL EXPENSE

Name

Title

Organisation

Address 1

Address 2

City Country

Phone                                                                     Fax

Email                                                                      Website

VAT Number (important):

I WISH TO JOIN THIS YEAR AS

( )        CORPORATE MEMBER                           Annual Fee: €1,500

( )        FULL MEMBER                                        Annual Fee: €500

( )        COUNCIL MEMBER                                Annual Fee: €250

Please tick the appropriate membership category

METHOD OF PAYMENT FOR YOUR ANNUAL FEE

Please choose your preferred method of payment. All payments must be remitted in EURO.

If you select payment by Credit Card, please fill in the details below, sign and fax the form back.

1) (  ) Credit Card
        I authorise Europe's 500 Entrepreneurs for Growth to charge my credit card for the amount of ............. EURO
        for payment of Annual Membership Fee.

           (   ) American Express                  (  ) Diners Club                    (  ) Visa / Mastercard / Eurocard

Credit Card Number: ..........................................................................................

Expiry Date: ...........................................              Cardholder’s Signature: ..............................................

2)  (  ) Cheque enclosed (by regular mail only):

         Bank:

         Number:

3) (  ) Bank Transfer processed immediately to     
        Bank - ING / Agence Cours Saint Michel
        Bank Address - Cours Saint Michel 40, B-1040 Bruxelles (Belgium)
        IBAN BE16 3101 2701 0674
      SWIFT BBRUBEBB 
      Payment Reference - Membership 2007