Reply form for Deputy leaders

(Please complete this form in Block letters)

Country :

Country code :

 

Last name :

First name :

Passport No :

Date of Birth :

Day :

Month :

Year :

Sex :

Male

Female

Languages speaking :

1st language

2nd language

Contact Address :

Telephone No :

Fax No :

E-mail :

Vegetarian :

Yes

No

Smoker

Nonsmoker

 

This form should reach IMO98 office by Fax or mail before June 1st, 1998