WIELS Club: membership registration form

Title

Name

Surname

E-mail

Address

Postcode

City

Country

Tel. / Cell no.

Membership fee

IBAN BE34 0014 0021 3790
BIC/SWIFT : GEBABEBB
Statement : WIELS Club 2014 + Name

*The membership fee is not tax-deductible.

I wish to receive WIELS Club invitations

I wish to receive the bi-monthly WIELS newsletter

I wish my name to be published in the biannual WIELS Brochure and the WIELS website

Quote

You can also support WIELS by making a tax-deductible donation via King Baudouin Foundation:

IBAN : BE10 0000 0000 0404 - BIC : BPOTBEB1

Reference: 128/0329/00004