Declaration of Membership

 

Starting on the following date _ _ _ _ _ _ _ _ _ , I declare my membership in Berggorilla & Regenwald Direkhilfe

Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Affiliation _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Address _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Birthdate _ _ _ _ _ _ _ _ _ _ _ _ _ _ _    Male O       Female O

O I want to receive the Gorilla Journal as printed copy

O Inform me when new issues can be downloaded. My email address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 

Date and Signature

___________________________________________________________________________

Yearly Subscription (please mark)

Members living in Europe

O  Euro 15 (Student)        O Euro 40 (General Member)

O  Euro 65 (Family)      O Euro 100 (Donor)

Members living overseas

O  US$ 25 (Student)        O US$ 75 (General Member)

O  US$ 120 (Family)      O US$ 180 (Donor)

Please print and send the completed form (together with your check) to:

Rolf Brunner
Berggorilla & Regenwald Direkthilfe e.V.
Lerchenstr. 5
45473 Mühlheim, Germany
Fax.: +49-208 / 7671605