Académique Documents
Professionnel Documents
Culture Documents
NameofapplicantsSection..................................................................................
Surname.................................................................................
Firstname......................................................................................
Nationality..................................
DateofapplicationtojointheAssociationsNationalorOpenSection...............
PRIVATEINFORMATION
Dateandplaceofbirth....................................................
Homeaddress......................................................................
Phonenumber.........................................
Faxnumber.............................................
Email.........................
DoyouauthorisethisinformationtobepublishedinAICA'sannualMembershipDirectory?*YES
NO
PROFESSIONALINFORMATION
Professionaladdress..
Phonenumber........................................
Faxnumber........................................................
Email
Websiteaddress
DoyouauthorisethisinformationtobepublishedinAICA'sannualMembershipDirectory?*YES
NO
Officialtitlesandqualifications
.
.........................................................................................................................
WewishtoremindyouthatunderArticle34ofFrenchlaw'InformatiqueetLibert'(theFrenchversionofaDataProtection
Act)youareentitledtohaveaccessto,modify,rectify,ordelete,anydetailsrelatingtoyourperson.Ifyouwishtoexercisethis
right,youshouldaddressyourequesttoAICA,32rueYvesToudic,75010ParisFRANCEorto :office.paris@aicaint.org
*
AICA32rueYvesToudicF75010Paris
http://www.aicaint.org
1/4
Regularcollaborationindailypapers,periodicals,radioorT.V.programmes(note
forhowlongyouhavebeenworkingforthem):
Long essays and/or books (note the title, editor, year of publication, number of
pages):
Doyouteach?(where?whatfield?)
Doyouworkformuseumsorculturalorganisations?(Whichones?)
Doyouorganiseexhibitions?(Whichonesandwhere?)
AICA32rueYvesToudicF75010Paris
http://www.aicaint.org
2/4
WNIOSEK CZONKOWSKI
Imi, nazwisko:
Instytucja:
Adres:
E-mail:
Telefon:
AICA32rueYvesToudicF75010Paris
http://www.aicaint.org
3/4
Podpis
Data
AICA32rueYvesToudicF75010Paris
http://www.aicaint.org
4/4