ENG - Enrollment Form   Français

I, the undersigned (followed by Last and first names printed) ________________________________________________________________

Company (if corporate adhesion) _______________________________________

Title in company _______________________________________________________

Street Address__________________________________________________________

Zip, City, Canton/State _______________________________________________

Day phone _______________________________________________________________

Fax ______________________________________________________________________

E-mail _________________________________________________________

Wish to adhere to the Galerie Quint-Essences in the quality of an enterprise c or individual c (please check the correct answer).

m    As a guest from time to time - you will receive a free invitation to openings by e-mail only

m     As a Member - you will receive invitations by postal mail and the "Quint-Essential News" 4 times a year - 120 CHF / year

m   Friend of the Gallery - all of the above as well as free entry to three paying activities per year of your choice fora  value of not more than the subscription as a Friend of 250 CHF / year

m      Friend of the Arts - all that a Friend of the Gallery obtains but you also sponsor an event during the year. We shall be happy to provide you with a list of activities from which to choose, such as conference speakers, performing arts on the roster, an artist's project, etc.) - 500 CHF / year.

Subscription signed at (city) _______________________________ date_____________

Signature _______________________________________________________________

Payment by m Mandat postal m BVR, made out to Harriette Laurent (request bank information)         m or in cash

Received on (date)_______________________

by the representative of the Gallery, (initials then signature)

 _________________________________________________________

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