New Technologies - APV

BULLETIN COTISATION A L’APGI 2012/ SUBSCRIPTION FORM TO APGI 2012
MEMBRE ACTIF ET MEMBRE ASSOCIE/ ACTIVE MEMBER AND ASSOCIATE MEMBER
Since July 1, 2010 the French VAT (19,60%) will be added to the amount of the subscription
*(TTC) €
2012 3 Ans/Years
Industrie/Industry ⃝ 165,00 ⃝ 495,00
197,34* 592,02*
Université, Hôpital, Retraité/
Academia, Hospital, Retired ⃝ 70,00 ⃝ 210,00
83,72* 251,16*
Co-inscription APGI + AFEPG
(Association des Enseignants Francophones ⃝ 80,00 ⃝ 240,00
en Pharmacie Galénique) 95,68* 287,04*
Etudiant/Jeune diplômé*, **/ ⃝ 25,00 ⃝ 75,00
Student/Young Graduate*, ** 29,90* 89,70*
*Diplôme de 3 e cycle obtenu depuis moins de 2 ans/ postgraduate diploma since less than 2 years
**Diplôme/Diploma
Ville/Town Année/Year
MEMBRE CORRESPONDANT/
CORRESPONDENT MEMBER ⃝ 200,00 ⃝ 600,00
239,20* 717,60*
MEMBRE BIENFAITEUR/
BENEFACTOR MEMBER ⃝ 500,00 ⃝ 1500,00
À partir de/from 598,00* 1794,00*
⃝ Oui, Oui, je souhaite participer à la journée d’information APGI/Unipex le 5 avril 2013. Journée gratuite pour les membres de l’APGI
Yes, I will participate in the APGI/Unipex Information Day on April 5, 2013. No registration fee for APGI members.
⃝ Oui, je souhaite m’inscrire et régler la cotisation pour 3 ans. J’éviterai ainsi toute augmentation de tarif pendant cette période
Yes, I would like to subscribe and pay for 3 years, this to avoid any increase of the fee during this period.
Nom/Name Prénom/First Name
Institution/Institution
Fonction/Function
Adresse/Address
Tél./Phone E-mail
Adresse de facturation/Invoicing address
MODE DE PAIEMENT/PAID BY
Paiement après réception facture/On receipt invoice:
Chèque ci-joint/Cheque enclosed
Carte bancaire/Credit card
⃝ Visa ⃝ Eurocard ⃝ Mastercard
No carte/Card No
Montant/Amount Expiration/Date of expire
Signature/Cardholderd’s signature
The data may only be used by APGI and its members. According to article 34 of the French Law entitled “Informatique et Liberté“ dated January,
6th, 1978, you have the right to access, modify and delete the data which regard you. To exercise this right or to indicate that the data should
not be used by our members, please write to: APGI at the following address:
APGI • 5, rue Jean-Baptiste-Clément • 92296 Châtenay-Malabry cedex (France), Tél.: +33(0)6 29 36 67 39 or +33(0)1 46 60 25 10 • Fax : +33(0)1 46 83 53 08
E-mail : apgi.asso@u-psud.fr • www.apgi.org, SIRET 434 287 447 00016 • TVA / VAT N° FR 63 434 287 447
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