Subscription form for commitment donation
Please print and return by fax or mail
Name:
Firstname:
Mrs
Miss
Mr
Address:

Zip code:

City:

Country:

Phone:

Fax:

E-mail:

Date of birth:
Date:.......................................
 Signature: ...................................

For a minor person, signature of the legal representative:


I/we would like to support the future foundation "Pass the Baton" by a payment of:

CHF:

Euro:

Payment will be done on (date):


Payments must be done on the following bank account:
Banca del Gottardo Lausanne
Account CD 648949.02 Clearing 8613
CCP 69-6966-7
Fondation "Passez le Relais"
P.O. Box 90
CH - 1816 Chailly-Montreux

This document must be returned duly filled out and signed to "Passez le Relais"
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