Firm Level Assistance Program

 

Registration Form

11
Company name:  

Main Business:

 

 

Established

Since:

  

Representative:

 

Title:

 

Address:

 

 

City:

 

 

E-mail:

  

Tel:

 

Fax:

 
Need:  
Date:   Signature:  

Please return this form to by email to at  register@pita-palestine.org or to Fax 02/240 8479.

PAYMENT [Filled by PITA]

Fees Paid:

Members: $200

Non-Members: $300

DATE:

PITA STAMP: