Please print this form and send by Fax (0049 30) 782 30 85 or mail to FGF, Konstanzer Straße 14, 10707 Berlin.

__  I become an official donor of the FGF and will be listed in the published list of donors.

        Please send me a donor certificate for

        __  $ 300,-

        Please send me a donor certificate for

        __  $ 3000,- , for which I will also be invited to all public events of the FGF as a special guest of honor.

__  I support the work of the FGF with a one-time donation in the amount of $ ______________

        __  Please send me a tax-deductible donation voucher.

__  I become a member of the FGF.

      The annual membership fee for full salaried individuals is $ 150,- (reduced fee $ 50,-).
      I may terminate my membership without notice at any time.

__  I have transferred the amount of $ ______________ to the account of the FGF:
      Bank account no.130 650 55, Berliner Volksbank, Hauptstrasse 109
      D-10825 Berlin, Germany, Routing code 100 900 00.

__  I am enclosing a cheque in that amount.
 

Name ____________________________________________

Street ____________________________________________

City _____________________________________________

State __________________________Zip________________

Phone/Fax/Email ___________________________________

Signature/Date _____________________________