Membership application form

 FREE LANCE INTERNATIONAL PRESS
via Federico Cesi 44 - 00193 Roma, Italy
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First and last name …………………………………………………………………………

Date of birth……………………….. 

City of birth………………………………………………………………………………………………

Address………………………………………………………………………………………………

Telephone (home or office) ……………………………………………………

Cell. no°………………………………

Fax (home or office) ………………………….

E-mail address…………………………………………. 

Tax code/VAT code……………………………….

Do you belong to other journalism associations (yes/no) …………….

Name and card number…………………… List…………………….

 

The undersigned stating on his own responsability that his prevalent activity is working as

a freelance reporter in the following sectors:

A) Print journalism (publications):…………………………………….(sector)…………………………………

B) Photography (publications)………………………………………………(sector)…………………………………

C) Radio/TV (publications)………………………………………………..(sector)………………………………

D) Other (please specify)……………………………………………..

 REFERENCES........................................................

 Telephone...............................................e-mail......................................

 HEREBY REQUESTS

To enter the Free Lance International Press Association as

an ordinary (70 Euro-Western Europe - Japan - Australia - Argentina - Cile -New Zeland - South Africa / 80 Euro-USA - Canada / 20 Euro-Other Countries)

-sustaining (120 Euro-Western Europe - Japan - Australia - New Zeland - South Africa / 160 Euro-USA - Canada / 40 Euro-Other Countries)
 
-founding (180 Euro or more).

Member

 

The undersigned will return his Free Lance International Press membership card should he not 

renew his yearly membership, and hereby states according to the terms of, and for all intents and 

purposes of, Italian law no 675 of December 31st 1996, that he permits Free Lance International Press 

to divulge the data set forth above by himself for all purposes permitted by the laws.

 

Signature of applicant ……………………………………………………………………………

______________________________________________________________________________________________

Attached are two passport-size photos, a photocopy of the receipt for payment of the bank transfer order for the sum corresponding 
to the membership qualification chosen or of his check payable to the association. For payment via banking:

Free Lance International Press-Banca Sella Ag. D7 - Roma - piazza San Giovanni di Dio  5 -COD.  IBAN:   IT 40 D 03268 03205 000878287460
                                      Cod. Bic/Swift : SELBIT2BXXX

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