IRISH FULBRIGHT ALUMNI ASSOCATION
MEMBERSHIP REGISTRATION FORM 2009
Personal Details
Name:
Occupation/Title:
Address:
Tel No:
Home:
Work:
Fax No:
E-mail:
Fulbright Scholarship Details
Year:
Venue:
Discipline:
Signed:
Date:
Irish Fulbright Alumni Association – Membership Subscription Form 2009
Name:
Subscription (please delete as appropriate)
€40.00
€20.00 / $25.00
(Members
resident in
Ireland)
(Overseas
Members)
or
Payment may be made by cheque or credit card.
I am paying by:
Cheque (made payable to the Irish Fulbright Alumni Association)
Credit Card
Please debit my credit card:
(Please delete as appropriate) Access / Visa / Mastercard / Eurocard
Card No.
Month
Expiry
Signature:
Signed:
Date:
Please print and return these forms to:
Dr. Dr. Sarah Ingle, 107 Connaught Street, Phibsboro, Dublin 7.
Please don’t forget to enclose cheque if using this method of payment.
Year