LICENCIÉ EXCLUSIF DE LA MARQUE DELAHAYE ©

CLUB DELAHAYE MEMBERSHIP FORM

LAST NAME :……………………………..…… FIRST NAME :…………………………

OCCUPATION : …………………………………………………………………………...

ADDRESS : …………………………………………………………………………………

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ZIP CODE : …………..... CITY : …………………………………...........................

COUNTRY :………………..............… TEL : ………………….... FAX : ..........................

MOBILE :…………………. E-MAIL : ……………………………………........................

DELAHAYE OWNER (1).....Oui / Non ........ FRIEND...Oui

Model : …………… Châssis N° : …………………… Year : …….......

Coachwork type : …………… Coach builder : …………………………...................

Additiona informations : ….……………………………………………………………..…

Wish to join DELAHAYE CLUB. The annual membership fee is :
85 € for Euro zone residents
140 $ or equivalent for other
I pay with check (to the CLUB DELAHAYE) or bank transfer. (1 ) (2 ).

Date : ……………………….Signature :……………………………………….

(1 ) Check appropriate mention
(2 ) For transfer to the Club Bank : CRCAM CRNS PACY SUR EURE
IBAN (International Bank Account Number) : FR76 1830 6002 2411 8656 0980 335
BIC (Bank Identification Code) : AGRIFRPP883
Please take into consideration any bank fee and mail to .:

Philippe BONNUIT - Société REPLEX
10 rue Alphand, 75013 PARIS
Tél : 01 45 80 47 77 Fax : 01 45 65 06 14 Courriel : philippebonnuit@orange.fr