ALLIANCE FRANCAISE D�INDIANAPOLIS

MEMBERSHIP APPLICATION FORM

A Special Invitation to Join

1 October 2001� -- 31 December 2002

Cat�gories� des cotisations:

Individuelle (Individual):�� $ 25.00�� Donateur (Contributor):�� $� 50.00

Familiale (Family):�� $ 30.00�� M�c�ne (Patron): �� $� 75.00

Compagnie (Corporation):�� $ 100.00

Etudiant Plein Temps (Fulltime Student):� �$ 10.00

(Photocopie de la carte d��tudiant obligatoire) (Please enclose photocopy of student ID card)

��

S�il vous pla�t, libellez votre ch�que au nom de �ALLIANCE FRANCAISE D�INDIANAPOLIS�, et envoyez-le accompagn� de ce bulletin � Liliane KRASEAN, President, ALLIANCE FRANCAISE, 6038 Castlebar Circle, Indianapolis, IN 46220.

�� BULLETIN D�ADHESION

1 Octobre 2001 --� 31 D�cembre 2002

Nom: ___________________________ �Pr�nom(s): __________________________________

Last Name�� First Name(s)

Adresse: ______________________________________________________________________

�Address

_________________________________________ T�l�phone: __________________________

E-Mail: _______________________________________ Fax: ___________________________

Cat�gorie de Cotisation: ___________________ Montant du ch�que joint: _______________

�Membership Category�� Amount of� Enclosed Check

Pr�noms & Ages de vos Enfants: __________________________________________________

First Names & Ages of your Children

_____________________________________________________________________________

Ville(s) habit�e(s) en Pays Francophones: ___________________________________________

�Places you have lived in French-Speaking Countries