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Dipl.-Betriebswirt FH Werner Seiß
Tel 09825/93451; E-Mail seiss@an-netz.de;

Herrn Werner Seiß
- Chairman -
Windmühlstraße 1
91567 Herrieden-Neunstetten

Application for Membership in the Förderverein Bürgernetz Ansbach-Netz e.V.

I apply for Membership in the "Förderverein Bürgernetz Ansbach-Netz e.V." (Supporting-Clup citzen-netzwork Ansbach-Net). I give the follwing statements:

Salutation:_________________________
Title: _____________________________
First name:_________________________
Last name: _________________________
Date of birth: _____________________

If you are a company additional:
Salutation: ________________________
Organization: ______________________
Department: ________________________
Position: __________________________

Street: ____________________________
ZIP-/Post-Code:_____________________
City: ______________________________

Intrest in project-teams, fields of
interest, concerns, suggestions and
requests (volontary statement)
____________________________________

Phone privat: ______________________
Phone business: ____________________
Fax: _______________________________
2nd. phone-No.: ____________________
E-Mail (now): ______________________
Homepage (now):_____________________

Maiden name of the Mother (to identify you for password
information): ______________________

Joining-date: ________________________
One time registration-fee 30,00 DEM
I/we join as total amount per month:
( )Private person 7,00 DEM
( )Member(s) of the family 0,00 DEM
( )Club 20,00 DEM
( )Company/Town up to 100 emp. 20,00 DEM
( )Company/Town over 100 emp. 50,00 DEM
( )School (0,01 DEM pupil per Monat (Minimum fee 7,00 DEM Monat)__________DEM
( )________________________ __________DEM

Minimum fee (except family-mamber (s))
7,00 DEM per month!

Member(s) of the family who become
club-members (without cost, only with private
persons, without e-mail/Homepage):
_________________ _________________
_________________ _________________
_________________ _________________

Desired E-Mail: ___________________________@an-netz.de

Bank: ___________________________________
Bank code number: _______________________
Account No. : ___________________________

I have completed this declaration to the best of my knowledge and belief, and I herewith give permission for automatic withdrawal from the above account. The total monthly amount includes membership dues and a taxable Internet usage flat fee for the Buergernetz Club Ansbach-Netz e.V., in the amount of 4.00 DM for full Internet access, including personal e-mail address and the option to activate a personal home page (3MB). I accept the articles of association of the club, as well as the respective version of the General Terms of Business of the Buergernetz Club Ansbach-Netz e.V. for the usage of the Internet. I understand that my data are being stored for administrative purposes. These and other documents may be accessed by contacting Mr. Seiss, or through the internet at http://www.an-netz.de/an-netz/, or they may be requested by sending a self-addressed, stamped envelope. Membership must be cancelled in writing by giving a 3-months notice for the end of a calendar year.

________________________________    ________________________________________________
City, Date Signature
Bürgernetzverein Ansbach-Netz e.V.