EFN-USA Membership registration form

Environmentalists For Nuclear Energy, Inc. is a 501(c)(3) tax exempt not-for-profit organization incorporated in the State of Delaware. All dues-paying members and contributors will receive a receipt. If you are a fiscal resident of the United States (your address below located in the US), you will receive a fiscal receipt in the first months of the following year.

Click here to download EFN-USA's membership registration form in PDF format to be photocopied and distributed to your friends, colleagues, neighbors and relatives

To become a member of the Association of Environmentalists For Nuclear Energy
FILL OUT, PRINT (to paper or PDF file) and RETURN this registration form to :

Environmentalists For Nuclear Energy
E-mail: nuc-usa[at]ecolo.org  (spam prevention: replace [at] by @)
Phone: (866) 445 0599 - Fax: +339 552 900 22

First name* :

Name* :

Address* :

State/Zip code* :

City* :

Country* :

E-mail* :

Phone :

Fax :

Profession :

Age :

years

(*) Required zone 

 

Please register or update my membership in the following category:

Supporting Member: I approve your action (FREE - send by fax or PDF file)
Sympathizing Member: US$ 30 for one year
Active Member:  US$ 60 for one year
Donating Member: US$ 120 for one year.

Dues-paying members will receive a receipt. You will be informed by e-mail.
New members are admitted subject to the approval of the Board of Directors.

I agree to be a local correspondent of EFN in my State or local area :
Additional donation to support EFN-USA : US$

Total amount: US$
paid by : cheque credit card bank transfer
to the order of: "Environmentalists For Nuclear Energy, Inc. (EFN-USA)"

 

 

Date :    Signature:  

  

 FIRST STEP : fill out, print and send this page to EFN-USA

After completing this form, select your printer (or PDF format) and click on the "Print" button to print this page. You can also use the "Print" button in the menu of your navigating software. 

This page can be printed either : 1/ on paper, in this case, fax the paper-printed form to +33 1 30 86 00 10 or 2/ this page can be printed to a PDF file (using ACROBAT WRITER or a similar software), in this case send the PDF file to nuc-us[at]ecolo.org (spam prevention: replace [at] by @).

Sign the printed paper version if you print this page on paper and send it to EFN by fax, or type your name or any alpha-numerical code legally representing your signature, for example : /John Smith/ or /jsmith8492xfp8902/ into the "signature" zone, if this page is printed to a PDF file and sent to EFN-USA by e-mail to nuc-us[at]ecolo.org (spam prevention: replace [at] by @).

 

 

SECOND STEP : send your payment by one of the three following methods

Payment by credit card (Paypal): click on the visa card logo below, and follow the instructions. Most credit cards are accepted (Visa, Mastercard, American Express...). The amount of your payment will be debited from your credit card. Do not send your card number to EFN-USA, please make the payment as indicated after clicking on the visa card icon below (Visa, Mastercard, and most types of credit cards are accepted).

click : for payment to EFN-USA by credit card in US dollars (USD)

  For our international friends: click here to open the currency converter (opens a new window containing the converter), click on the currency of your choice. Once you have determined the amount in US$ that you wish to donate, click on the credit card above.

Payment by bank transfer (in US$): send an e-mail to nuc-us[at]ecolo.org (spam prevention: replace [at] by @ in your email before sending the message) asking for instructions concerning payment by electronic bank transfer. You will receive instructions by e-mail.

According to the law, you have the right to access and correct the computerized information which concerns you.