Arbeitskreis Geschichte der Nachrichtendienste e

							         Arbeitskreis Geschichte der Nachrichtendienste e.V.
 INTERNATIONAL INTELLIGENCE HISTORY ASSOCIATION
                       Website: http://www.intelligence-history.org/
                Postbank Hamburg, Kto.-Nr. 768623-205 (BLZ 200 100 20)
                 IBAN DE36 2001 0020 0768 6232 05 (BIC PBNKDEFF)

                      MEMBERSHIP APPLICATION FORM /Mitgliedsantrag

Membership fee is due 31 March of each year. Please complete this form (attach business card or print
using block letters) and mail/fax/e-mail to: IIHA, Executive Director Malte Roschinski, P.O. Box 11 55,
D-78228 Engen, E-mail: exec_director@intelligence-history.org


LAST NAME:                                       FIRST NAME:

RANK:                                            TITLE:

UNIVERSITY NAME/ORGANIZATION:

ADDRESS:

___________                                      HOME ADDRESS         □ BUSINESS ADDRESS □
POSTAL CODE/CITY:                                                COUNTRY:

TEL:                            FAX:                             E-MAIL:

Tick the appropriate boxes:
□       Regular membership 50,00 €
□       Student membership 25,00 €
□       Bank transfer to Postbank Hamburg, BLZ 200 100 20, Account No 768 623 205, BIC
        PBNKDEFF, IBAN DE36 2001 0020 0768 6232 05
□       Credit Card: charge my credit card for the amount of:
        My      □   Visa                        □     Mastercard/Eurocard number is:




Cardholder name:                                 Expiration date:


Signature:                                       Date:

DATA PROTECTION: The information you provide on this form will be held
on a database and will only be made available to organizing individuals of the association.


Vorstand/Board: Prof. Dr. Shlomo Shpiro, Prof. Dr. Wolfgang Krieger, Dr. Sigurd Hess,
Dr. Gerhard Schmid, Malte Roschinski