FATU-HIVA International Inc.
To be completed by the Club ONLY
A. Number:
FH
First Name (s)
Title
Surname (s)
1
2
3
Mailing Address:
City / Town
State/Province
Country
Postal Code
Other Phone Number
E-Mail Address:
PART "A"  - Object of this Membership Application and Agreed Level
Level Applied for:
Points  / Year
Applic. Fee
The amount obtained by converting the "Applic. Fee" to your country's currency, should be
the one shown on the AMOUNT box  of Par "B" - Payment Breakdown of this Application.
Confirm the Membership Fee in Words:
PART "B"  - Payment Breakdown
Unless otherwise specified and approved by the Club, the subscription fee due for each Level, shall be paid in the manner and/or installments agreed, as follows:
Terms
Times
Amount
Currency
Due Date
Method of Payment
For payments made by Credit Card, please provide the following information:
No spaces or dashes
Expiration Date:
Card Type
Card Number
MM
CSC
YYYY
FATU-HIVA's Representative should complete this box.......
PART "C"  - Terms of the Agreement
Continue to Page # 2
TRAVEL & RECREATION SERVICES
FATU-HIVA Holiday Club
Home Phone Number
Cell Phone Number
Work Phone Number
MEMBERSHIP APPLICATION
F
H
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if paying by PayPal
Application dated:
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