Membership subscription form

Personal Data

Title First name Last name dob handphone
 
 
 
 
 

Residential addres
Phone
Fax
E-mail
Communication language
BLAS join date
* Do you want to receive a paper copy of the BLAS gazette?
yes
** Do you wish to receive third party information by e-mail?
yes
If yes, to which e-mail address can the 3rd party emails be sent?

* The Blas gazette is also available online in pdf-format
** Our address list is not given out to external parties. Nevertheless, we sometimes forward email messages to our members when we find it useful.

Membership fees 

S$ 50,- for a student membership

S$ 160,- for a family membership

Membership payment 

bank cheque nr

    Cheques to be paid to: BLAS.

    Cheques to be sent to:

    Bieke Bouckaert
    309 Jalan Kampong Chantek
    Binjai Crest
    Singapore 587962

    Email:

Do you need a receipt

Employment Data

Adult 1 Company name
Company address
Phone
Fax
Website
E-mail
Adult 2 Company name
Company address
Phone
Fax
Website
E-mail

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