Application FORM For Membership

Last Name (Family Name)

First Name

Initial(s)

Degree:

Mailing Address:

City:

Postal Code:

State:

Country:

Business Phone: +

Fax: +

E – Mail

Signature:

Date:

This document must be sent to the WFLD Secretary:

Rua Groenlandia, 183

(Jardim América)

01434-000 Sâo Paulo, Brazil

Fax 55 11 3885 1392

E-mail abrugnera@uol.com.br