HOÄI VAÊN NGHEÄ SÓ VIEÄT NAM TÖÏ 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

 

ÑÔN GIA NHAÄP  

 

Soá Ñôn G.N. _____________

Hoï vaø teân: _____________________________________    Thi hieäu, Buùt hieäu________________________________

Naêm sinh __________________  Nôi sinh _____________________________________________

Ñaõ hoaït ñoäng trong moät hoaëc nhieàu boä moân Vaên Hoùa, Ngheä Thuaät: Thi [  ] Vaên [  ] Hoïa [  ] Nhaïc [  ] Kòch [  ]

    Ñieâu Khaéc [  ] Nhieáp AÛnh [  ] Ñieän AÛnh [  ] Phaùt Thanh, [  ] Truyeàn Hình [  ] Baùo Chí [ ] Pheâ Bình [  ] v.v...)  

    ______________________________________________________________________________________________

Ñòa chæ: _________________________________________________________________________________________

________________________________________________________________________________________________

Ñieän thoaïi ___________________________ (nhaø)     _______________________________ (sôû/cell)

Fax _______________________________     E-mail ____________________________________________________

 

Toâi ñaõ ñoïc Baûn Ñieàu Leä vaø taùn ñoàng Toân Chæ & Muïc Ñích cuûa Hoäi.

Yeâu caàu ghi teân toâi vaøo danh saùch Hoäi Vieân.

* Hai hoäi vieân giôùi thieäu:

1. ______________________________________________________________________________________________

2. ______________________________________________________________________________________________

Laøm taïi __________________________________     ngaøy __________   thaùng __________   naêm _______________

 

Kyù teân  

 

______________________________________

 

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