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Silesian Esperanto
Association
Membership Application Form
Forename (s)
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Surname
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Date of birth
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Address
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e-mail
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http://
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Tel.
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Language (s) .........................................................................................................................
Hobbies
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I wish to become a ordinary (benefit*) member of the Silesian
Esperanto Association.
I send my membership dues of ....................
for the year ..........................
by postal order
to the following address:
Silesian Esperanto Association
ul. Dubois 3/1
PL-50-208 Wroclaw
Lukas Bank Wroclaw
(IBAN) PL 90 1940 1076 3026 8339 0000 0000
SWIFT (BIC code): LUBWPLPR
Date ........................................
Signature .......................................................................
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