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Name, Affiliation ………………………………………………………..

Date of birth …………………………………………………………

Sex ………………………………………………………….

Occupation …………………………………………………………..

Address: Street: …………………………………………………

Postal code, City ………………………………………………..

Country: ……………………………………………….

Phone: …………………………………………………

Fax: …………………………………………………..

E-Mail …………………………………………………

Type of membership:

Ordinary member (individual)

Ordinary member (Institution).we enclose documents about works and aims of institution

Sponsoring member

Special interest in Astronomy:

special interest in the EAAE

Place, date: Signature:

For individual only:

My member ship is recommended by:

Name, affiliation

Address

Place ,date Signature

Name, affiliation

Address

Place ,date Signature

Inviare il modulo compilato per posta ordinaria alla rappresentante nazionale:

Cristina Palici di Suni

Via Giulia di Barolo 3

10124 Torino