BPRI Membership Registration Form 2012 Name: First name Gender:   male    female  Company Function Address Telephone Fax E-mail adress Membership:   I would like to become a new member of the BPRI (Individual)       My Company would like to apply for the Company Membership    I would like to renew my membership for 2012       I would like to cancel my membership    Please sent me more info concerning membership  How much to pay ?   Full Membership  Euro 60,==    Retired Members  Euro 30,==    Students Free    Company Membership  Euro 250,==  How to pay ?   I will send a crossed cheque made out to the BPRI    Bank transfer to Dexia Banque account nr 776-5957938-04  FOREIGN MEMBERS are requested to mention clearly IBAN and BIC codes. IBAN: BE10-7765-9579-3804 BIC: GKCCBEBB Please show the name(s) of the delegate(s) on the payment form as a reference. Please give details about your major Polymer interests at BPRI

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