Membership and Support Form Mr. Ms./Mrs./Miss Association or Organisation Family or organisation name (Capital letters): ___________________________ First name: _______________________________ Date of birth: ____/____/____ Profession or field of work:______________________________________________ Address: _________________________________________________________________ Postal Code: _________________________ City/Town: ________________________ Country: _____________________________ E-mail: __________________________ Telephone: ___________________________ Fax: _____________________________ * I would like to join the Caravan association and am hereby sending my payment for 2000/2001 30 US$ (for people from "developing" end "emerging" countries, students, unemployed people) 60 US$ (for working or retired people from industrialised countries) * I would like to contribute to the publication of Caravan in 2000/2001 by donating: 15 US$ 30 US$ 45 US$ Other: _____US$ Payment made by: bank or postal cheque, in French Francs or Euros, made payable to "Association Caravane". (for France only) direct payment to the association's account: CCP, 45900 La Source, France: N° 20041 / 01012 / 4542629F033 / 64 credit card (number): ____________________________________ Holder's name: _________________________________________________________ Expiry date: _______________ Signature: _______________________________