Surname ...................................................................................................................

Name........................................................................................................................

Address.....................................................................................................................

..................................................................................................................................

Telephone number......................................................................................................

Profession .................................................................................................................

desires to join the AT association as:

MEMBER:     Ordinary                            Supporter

                        Worthy                                Benefactor

Date.............................Signature...............................................................................

Annual membership fees begin from a minimum of:

- Ordinary member............................................................L.         20.000

- Supporter member........................... ..............................L.       150.000

- Worthy member..............................................................L.       500.000

- Benefactor member........................................................L.    1.000.000

The payment of the membership fee made out to: AT-Ass.ne "Davide De Marini" Ricerca Prevenzione Terapia Sindrome di Louis Bar

Vicolo Gallizi,  19  -   61032   FANO (PS)

has been made in the following way:

-      Bank current account

      Banca Naz.le del Lavoro - Ag. di Fano

      ABI 1005 - CAB 24300 - C.C. n°9111

-     Bank current account

     CARIFANO S.p.A.

     Cassa di risparmio di Fano - Sede Centrale

     ABI 6145 - CAB 24310 - C.C. n°11734/57

-     Post-office current account n°10448611