Back

Application Form
Please print this form, fill it out, and mail it to:

FRIENDS OF THE SEGOVIA MINT
Apartado 315
E-40080, Segovia, SPAIN

Name___________________________________________________

Address_________________________________________________

City_______________________________  Postal code___________

State / Province________________    Country____________________

Telephone___________________________    Fax________________

E-mail_____________________@___________________________

ANNUAL DUES:   (12 euros) ($15 US)

PAYMENT METHODS:

Money order or postal draft made out to the Association

Personal check made out to the Association

Direct deposit in the Association's account in BANKIA:
      Account code:    bank 2038 office 7597 control 51 account 6000147991
      IBAN:  ES_38_2038_7597_51_6000147991
      BIC o SWIFT:   CAHMESMMXXX

Authorization for automatic withdrawal.

I authorize my bank to automatically pay my annual dues to the FRIENDS OF THE SEGOVIA MINT Association from my following account (please fill in the information):

My bank's name and address___________________________________________

Bank___________ Office________ Control______ Account___________________


(Date)____________________  (Signature)_______________________________