BELGIAN TIBETAN BREED CLUB ANNO 1969-2010

Accession form

Head Member in Belgium ...........22 €
Head Member from foreign countries ..27 €

Name : ............................. ..............Firts name:
Address : ..........................
Entry................................. ............................ Domicile :
Country : ..........................
Telephone Nr /GSM Nr : . ...E-mail :
Name of the dog : ............ ................. Breed .:

Date : ............................ . ..............Signature :

Member of the family in Belgium ..............12 €
Member of the family from foreign countries .....14 €

Name : ............................ ..............Firts name:
Address : ........................
Entry : ............................. ..............................Domicile :
Country : .........................
Telephone Nr /GSM Nr : .... E-mail :
Name of the dog: ............ ..................Breed : .

Date : ............................. ..... ......... Signature :

Payments can be done on our Club account addressed to   

Mr Robert Mittemeijer
Pierre van Gehuchtenstraat 1
2030 Antwerpen België
N° 750-9469655-91
IBAN BIC AXA BBE22
BE 2375094696559