Adhesion - Orderofleopold

First Name : *
Last Name : *
Title :
Date Of Birth : *
Place Of Birth :
Profession : *
Address : *
Postal code : *
City : *
Phone :
GSM :
Email Id : *
Current rank in the Order of Leopold :
Date of the Royal Decree relating to this grade :
Declare wanting to join the Society of the Order of Leopold as a member : * NOTE: member = quality reserved for widowers not remarried of decorated and orphans of decorated aged under 25
Life member : single payment of 20 times the contribution of the chosen quality
I accept that the following data will be published in the list of members of the Society of the Order of Leopold :
Position held :
Telephone or GSM :

Membership form to print.