2017 6B, 7A & 10B

FORM R21C

3501

: 1. 2. 3. () Call (Badge) Name () Family Name () Given Name

(2017-18) RC ARC RPIC ARPIC RRFC ARRFC EMGA EPNC

DG(17-18) PDG(16-17 and earlier) DGE(18-19) DGN(19-20) AG (17-18) Club-P PP Rotarian

: : :

: 1. ___________________ 2. 3.

:

E-mail : _____________________________________________________________________________________________

: +________________________ : + ______(______)______________ : +_______________________

(GETS) () NT$ 11,000 NT$ (GNTS) () NT$ 5,100 NT$ (DTTS) NT$ 3,150 NT$ (RRFS) () NT$ 2,800 NT$ () NT$ 3,800 NT$ () NT$ 6,300 NT$ () NT$ 4,100 NT$ (+) NT$ 10,000 NT$ NT$ : 1. 2017 10 31 1000

2. 2017 10 31 .

1. 2. Visa 3. MasterCard

Exp : Security Code :

_______________________________; ()______________________________

: +886-37-481768 Email : derkunwu@gmail.com PP Peter Wu : +886 932 613 766 2017taipeirotaryinstitute.org

(GETS) November 29-30, 2017 9:00-17:00 (GNTS) November 30, 2017 9:00-17:00 (DTTS) November 30, 2017 9:00-17:00 (RRFS) December 1, 2017 9:00-14:00 November 30, 2017 7:00-13:00 December 1-3, 2017

2017 12 1 - 3

.

Call (Badge) Family Name First Name

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