Contact form for the supporters of Conservative Institute of M. R. Štefánik
The Conservative Institute of M. R. Štefánik Club of Supporters (CICS) is informal society of CI donors and no obligations or responsibilities result from its membership. Names of CICS supporters will be revealed only after their consent. CICS will honor requests for anonymity of those CICS members that wish to remain anonymous.
Name and Surname / Company name *
(fill in your name and surname. In case of corporate donors, fill in company name)
Your answer
Bonus
1) Are you interested in including you (or name and logo of the company) as a donor on the CICS webpage? *
2) Are you interested in obtaining free copy of “In Defense of the Free Market” (Book is sent until depletion of stocks) *
Contacts
Email address: *
(fill in your contact email)
Your answer
Cell phone:
(optional)
Your answer
Mailing address:
(if you answered question no. 2 affirmatively, fill in your mailing address)
Your answer
Payment
Fee is being paid by bank transfer in the name of CICS bank account (No. of account: 2622455666/1100, IBAN: SK85 1100 0000 0026 2245 5666, BIC / SWIFT CODE: TATRSKBX, variable symbol: 2011777, constant symbol: 0558 and as a note for the recipient “CICS – name and surname”).
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service