Application Form

APPLICATION FORM

CLEAN UP THE MED 24-25-26 May 2013 Organisation Reference person: Telephone contacts: e-mail: Website or facebook page: PLEASE INDICATE AN ADDRESS TO SEND THE MATERIALS TO AND WHERE SOMEONE CAN RECEIVE IT ON WORKING DAYS IN OFFICE HOURS

Name of responsible for the actions Address City Telephone e-mail

Post code

Country

The organisation will set up the following initiative (thick as appropriate): INFORMATION POINT Place Date and time

BEACH CLEAN UP Place Date and time Activities planned:

OTHER Place Date and time Activities planned Send back this form by: • e-mail: cleanupmed@festambiente.it ; • or fax: + 39 0564 487740

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or post: Clean Up the Med – Legambiente Mediterranean Observatory – 58100 Rispescia – Gr Italy