Form of Contribution to the Terredelsud Association

Associazione Terrededelsud

Form of Contribution

The Undersigned Born to

in date Fiscal Code

Resident to Street/Square

e-mail

Considered valid the finalities of the Terredelsud association headquartered in 22, Pò Street - 00198 Rome.

contributes with the sum of €

We beg you to insert in this box the data of the check or the receipt of the payment THANKS -

The present sum will be poured on the c/c 108578 - ABI 05018 - CAB 03200 - of the Etica Bank - Filial of Rome - and recorded nominally on the book of the association.

Netscape Microsoft Lynx None of these

You can insert here the relative message to the demand.

The Undersigned		Born to
in date		Fiscal Code
Resident to		Street/Square
e-mail