| Family name | ||
| First name | ||
| Address | ||
| Phone and/or Fax number |
||
| wishes to become member (please tick the required category) | ||
| **with annual permanent payment order | |||
| Associate member Young friend (19 to 25 year) | 15 euro | 13 euro | |
| Associate member individual | 50 euro | 45 euro | |
| Associate member couple (2 membership cards) | 75 euro | 70 euro | |
| Full member individual | 100 euro | 90 euro | |
| Full member couple (2 membership cards) | 150 euro | 140 euro | |
| Patron of the Museum | 250 euro | 240 euro | |
| Patron couple (2 membership cards) | 300 euro | 290 euro |
| of friends of the Royal Museum of Fine
Arts of Belgium, and pays the sum of____________ euro. |
|
| * I have remitted this sum on account N° CCP 000-0196786-70 | |
| * Please debit my VISA or EUROCARD n°/.../.../.../.../.../.../.../.../.../.../.../.../.../.../.../.../ valid : ../.../.../.../ |
|
| date____________________ | signature_____________________ |
| * Delete as required | |
| **If you choose to pay by direct debit please point it on PDF and send it to your bank. We will send your membership card on receipt of your subscription. | |
| Tax deduction certificate
: If you want a tax deduction certificate (minimum 30 euro in addition to your dues) mention clearly upon your transfer order. |
|