FINANCIAL SUPPORT DONATION FORM          

(Please write in capital letters, mandatory fields are marked*)

Name*
Family Name*
A valid E-Mail*
Address*
City*
State/Province*
Country*
Zip Code*
Telephone
Fax
Organization*
Position*
Check one only position*
 

POSITION

FEE AMOUNT

Entry 

10,00 €

Supporter 

50,00 €

Gold 

100,00 €

Platinum 

500,00 €

Other

My organization wants to sponsor the campaign.  Please contact me directly

   

Check one only position*

 

PAYMENT METHOD

Credit Card - PayPal

Direct Bank Transfer (Bonifico) on: 

ACCOUNT: 005144545890 headed to Tecnologie di Frontiera 

- ABI: 03268 - CAB:44390 - CIN:IT95C 

- IBAN: IT95C 0326844390 005144545890

- SWIFT CODE: SELBIT2BXXX

[Banca Sella - Agency of Cavaglià (BI) - Italia ]

Postal cheque to: Adriano Autino, via Borgomasino 25/A 13040 Moncrivello (VC) ITALIA

     

Your personal data will never  be given to any other entity, for any purpose different from the support to the  Right to Space campaign.

By clicking the SUBMIT button, You give your consent to treat your personal data as per the privacy italian law (L.675/96).  

   

  [021.AA.TDF.2006 - 06.11.2006]