Membership Application Form / Formulário de solicitação de associação

Acceptance subject to approval by the board ( aceitação sujeito à aprovação pela diretoria)
Please fill in/ sign and send to fax 11 3221.9242 (Favor preencher, assinar e enviar via fax ou scaneado por e-mail)

PLEASE RETURN A SIGNED COPY OF THIS FORM TO FAX (55) 11 – 3221.9242

OR SCAN IT AND MAIL IT TO INFO@DUTCHAM.COM.BR OR NLOFFICE@DUTCHAM.COM.BR

FULL OFFICIAL COMPANY NAME IN THE NETHERLANDS:
VISITING ADDRESS:
POSTAL CODE:	CITY:
COUNTRY:	WEB-SITE:
PHONE:	FAX:
CONTACT PERSON:
CONTACT PERSON E-MAIL ADDRESS:
GENERAL E-MAIL ADDRESS:

BRAZILIAN SUBSIDIARY OR MOTHER COMPANY, IF:

FULL OFFICIAL COMPANY NAME:
CNPJ TAX NUMBER:
STREET ADDRESS WITH NUMBER:
POSTAL CODE:	CITY:
COUNTRY:	WEB-SITE:
PHONE:	FAX:
CONTACT PERSON:
CONTACT PERSON E-MAIL ADDRESS:
GENERAL E-MAIL ADDRESS:

MEMBERSHIP FEES TO BE PAID IN ( ) THE NETHERLANDS ( %)
( ) BRAZIL ( %)

GLOBAL NUMBER OF EMPLOYEES: (UNDER THE SAME COMPANY IDENTIFICATION):

MANAGEMENT PRINCIPALS (NAMES, FUNCTIONS AND E-MAIL ADDRESSES):







SIGNED BY:	POSITION:
DATE: SIGNATURE: REMARKS:

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