| Last Name: |
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| First Name: |
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| Birth Date (TT.MM.JJJJ): |
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| Street and No.: |
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| Postal Code:
|
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| City: |
_______________________________________ |
| Country of Origin: |
_______________________________________ |
| Partner's Name: |
_______________________________________ |
| Telephone: |
_______________________________________ |
| eMail: |
_______________________________________ |
| Remarks: |
_______________________________________
_______________________________________
_______________________________________
|
_____________________________
Place and Date
|
_____________________________
Signature
|
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Asian Ladies Club of Switzerland
Obere Zäune 8
8001 Zürich
|
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