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HOI VAN NGHE S VIET NAM T DO  

Association of Free Vietnamese Writers and Artists 

1 Applegrath Court, Germantown, Maryland 20874 (U.S.A.) * Tel. (301) 972-6540

E-mail: vinhliem9@hotmail.com

 

N GIA NHAP  

 

So n G.N. _____________

Ho va ten: _____________________________________    Thi hieu, But hieu________________________________

Nam sinh __________________  Ni sinh _____________________________________________

a hoat ong trong mot hoac nhieu bo mon Van Hoa, Nghe Thuat: Thi [  ] Van [  ] Hoa [  ] Nhac [  ] Kch [  ]

    ieu Khac [  ] Nhiep Anh [  ] ien Anh [  ] Phat Thanh, [  ] Truyen Hnh [  ] Bao Ch [ ] Phe Bnh [  ] v.v...)  

    ______________________________________________________________________________________________

a ch: _________________________________________________________________________________________

________________________________________________________________________________________________

ien thoai ___________________________ (nha)     _______________________________ (s/cell)

Fax _______________________________     E-mail ____________________________________________________

 

Toi a oc Ban ieu Le va tan ong Ton Ch & Muc ch cua Hoi.

Yeu cau ghi ten toi vao danh sach Hoi Vien.

* Hai hoi vien gii thieu:

1. ______________________________________________________________________________________________

2. ______________________________________________________________________________________________

Lam tai __________________________________     ngay __________   thang __________   nam _______________

 

Ky ten  

 

______________________________________

 

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