Print the following registration form, complete it and return it to the address given. All members are encouraged to interface directly with the PMP members.
REGISTRATION FORM
I hereby endorse the Erice and Farnesina Statements, and the Lausanne Declaration, and wish to become a member of the World Federation of Scientists.
Signed this ……………………………., in …..…………….
Signature
Name ……….………………………………………………..
Title ………………..……………………………………….
ORGANISATION / INSTITUTE
Name:……………………………………………………………………………………………………………………………………………………………………………………………………
Address ………………………………………………………………………………………………….………………………………………………………………………………………………...
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Telephone No: General ……………………………..….. Direct :……………………………Fax No: …………………………….……….. e - mail: …………………………………………….
PRIVATE ADDRESS :
………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………….
Tel/Fax. No. : ……………………………..… e - mail:……………………………………………..I prefer to be contacted at q my place of work q my home address, by …………………..
I am particularly interested in the following Planetary Emergencies: ……………………………
………………………………………………………………………………………………………………….
I am enclosing a:
Return this form to:
World Federation of Scientists
CERN - LAA Experiment
Building #29
CH-1211 Geneva 23
Switzerland