Application Form
for new members of LIA - Logosynthesis International Association
Last name *
Your answer
First name *
Your answer
Title
Dr., M.A., M.Sc. etc.
Your answer
Profession/Qualification *
max. 100 sings (blanks included)
Your answer
Company
max. 50 sings (blanks included)
Your answer
Address *
Street and number
Your answer
Postal code *
Your answer
City *
Your answer
Country *
Your answer
Email *
Your answer
Web Address
Your answer
Office phone 1 *
Your answer
Office phone 2
Your answer
Counselling by skype *
If yes: indicate skype name
Your answer
Counselling languages *
Your answer
I'm already a practitioner and register as a Professional member *
I agree to pay the annual contribution of € 110 or CHF 150.- / The above data will appear alongside the certified practitioners listed on the website www.logosynthesis.international
I'm interested in Logosynthesis/am in training and register as a Basic member *
I agree to pay the annual contribution of € 50 or CHF 70.-
I make a one-off contribution to LIA:
Please indicate amount and currency (Euro or CHF)
Your answer
I will pay the annual contribution: *
Bank details
BIC Code: POFICHBEXXX
Name and address of Bank: Postfinance, Mingerstrasse 20, CH-3030 Bern
Name and address of Association: LIA - Logosynthesis International Association, CH-8000 Zurich
I could undertake responsibility for the following for LIA:
Your answer
Comments
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