Follow the attached schemes

“Libera. Associations, names and numbers against mafias”
Membership campaign 2016
INDIVIDUAL MEMBERSHIP APPLICATION
TO BE FILLED IN CAPITAL LETTERS
Please fill in and send to Libera National Secretariat
By post to the address via Quattro Novembre, 98
00187 Roma (Italy)
to the attention of UFFICIO TESSERAMENTO
or by fax to the number +39066783559 o by email to [email protected]
For information - +390669770333
I, the undersigned ...................................................................................................
Place of birth ..................................................................................................................
Country and place of residence .....................................................................
Region/province ........................
Address .............................................................................. ZIP code .................
Date of birth (dd/mm/yyyy) ......../........./........... Phone number .............................
E-mail ….............................................................................
I got in contact with Libera through ..............................................
PRESENTS THIS APPLICATION FORM FOR:
new membership application
renewal of membership – I was already in the member in the years ….......................
Please attach copy of the payment addressed to:
Name account-holder: “Libera. Associazioni, nomi e numeri contro le mafie”
IBAN: IT 35 O 031 27 0320 6000 0000 00166 – SWIFT/BIC: CCRTIT2TT84A
Rationale: Membership fee 2016
Address organisation: Via IV Novembre 98 – 00187 Roma – Italy
• Ordinary member with Narcomafie, italian magazine in pdf subscription - 15 €
• If you experience difficulties with the magazine subscription please write to :
[email protected]
Informative text according to the provision of the art. 13, D. Lgs. 196/ 2003 –
Personal data is processed exclusively by those authorised with automated tools and Libera,
Associazioni nomi e numeri contro le mafie is responsible for the treatment and will use the data for
the shipping of informative and promotional material of the association and related to the activities
of the association. The data here communicated will be diffused only for the information
management and will not be leased and/or transferred to third parties or abroad. According to art. 7
law 194/2003 you will be able to request to modify or cancel you data or to oppose yourself to their
use addressing a request to Libera. The undersigned declares of having been here informed by
Libera about all the elements foreseen by art. 13 law n.196/2003 concerning privacy and expresses
the consent to the treatment of his/her own personal data for the purposes here mentioned and in the
limits required and established by law.
Date and place ............................................. Signature ......................................
Libera. Associations, names and numbers against mafia. Registered office: Via IV novembre 98 00187 Roma ITALY tel. 0669770328 fax 066783559 www.libera.it - e-mail: [email protected]
VAT number 06523941000 C.F. 97116440583