Il/La sottoscritto/a________________________________________________________________Nato/a
a ;__________________________Provinciadi :____________________il :______________
Professione :________________________________________________________________
Occupazione o
carica :______________________________________________________________
Ditta o Ente :_____________________________________________________________________
Indirizzo :
_______________________________________________________________________
Cittą :________________________Provincia di :______________________CAP :_____________
Tel :__________________Fax : ___________________e-mail :_______________________ __
Domanda di essere iscritto/a all'ANDIS in qualitą di socio :