Online Membership and Payment by Cheque

* Mandatory fields.
SURNAME *
FIRST NAME *
EMAIL *
TÉLÉPHONE
POSTAL ADDRESS
If couple : NAME OF THE SECOND MEMBER
EMAIL OF THE SECOND MEMBER PERSONNE
	Single Member : 15 € Couple : 20 € Student, job-seeker : 10 € Benfactor : minimum 150 €
MESSAGE
Please send a cheque to the address below, made payable to "Association Jean Bruneau" made payable to "Association Jean Bruneau" : Association Jean Bruneau 19 rue des droits de l’homme 44100 NANTES FRANCE