GAC-EPA — Groupement des Anciens du CERN-ESO Pensioners' Association

Membership Application Form

I wish to join* the GAC-EPA (Groupement des Anciens du CERN - ESO Pensioners' Association)

(explanations for filling in this form)

Personal details
title first name family name
I was formerly employed by  CERN   ESO   
last division/department
date of birth:
nationality:
Postal Address
number street
country postal code city
Communication
Telephone (optional)
Mobile telephone (optional)
e-mail
re-type e-mail:
(both e-mail addresses must be identical)
communication preference
My subscription of 30 CHF per year will be paid by standing order (excluding any other mode of payment) with execution date of 7 January of each year, to the UBS account of the GAC-EPA, IBAN CH47 0027 9279 C710 9245 0.
I will use the order message "membership GAC-EPA" followed by my complete name.

The content of this form will be sent by e-mail to me.
Protection
Protection against unsollicited messages:  before you can submit your data, click the digits in the grid on the right to make the four digit verification code. verification code:

Privacy:  the data sent in this form will remain confidential;  they will be used only for the purposes of accounting and the distribution of messages/documents that are deemed important to the members of the GAC-EPA.

* Art. 1.4 of the GAC-EPA Statutes states: The Association is open to all beneficiaries of the Pension Fund, whether their retirement is effective or delayed, including widows, widowers and orphans