Adhérer à la CPTS

Information adhérent
Nom*
Prénom*
Date de naissance*
E-mail*
Username d-none*
Mot de passe*
Répéter votre mot de passe*
Téléphone portable*
Téléphone fixe
Profession*
Adresse professionnelle*
Code postal*
Ville*
Numéro RPPS ou Adeli*
Je déclare par la présente souhaiter devenir membre de la CPTS.*
A ce titre, je déclare reconnaître l'objet de l'institution, et en avoir accepté les statuts.*
J'ai pris bonne note des droits et des devoirs des membres de l'association, et accepte de verser ma cotisation due pour l'année en cours.*
- J’accepte apparaître sur la cartographie de la CPTS du VEXIN Francilien.
Je souhaite m'inscrire à la lettre d'information de la CPTS.
Montant des cotisations
Adhérent - 20€ until 31 décembre 2024
Code promotionnel :
Vérification du code en cours...
Honeypot

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Détails de facturation
Prénom (facturation)*
Nom (facturation)*
E-mail (facturation)*
Entreprise (facultatif)
Si le champ est rempli, son contenu apparaîtra sur la facture et remplacera le prénom et le nom.
Adresse*
Ville*
Code postal
Pays*
État/Région/Département

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Information adhérent