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\begin{document}
	
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	\begin{center}
		{\bf Membership form}
	\end{center}
	
	I undersigned {\sf Mr / Ms} \dotfill \\
	certifies on the honor to have read and understood the \emph{ARM rules and regulations} and I am committed to respect it.
	
	In confirmation with the article 27 of the French law of ``Information and Freedom'' of January 6, 1978, you have the right of access and of rectification to your information.
	
	\setstretch{1.3}
	
	\begin{center}
		\begin{tabular}{ll}
			{\bf Subscription} \\
			\hline
			Subscription fee :  \\
			Cable :  \\
			Adaptator TU2 -- ET100 : \hspace{1.5cm} \\
			Misc. : \\
			Total amount :  \\
			\hline
			Paid by {\sf check / cash} \\ % US translation
		\end{tabular}
	\end{center}
	
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	\noindent Signed and accepted in Metz on (dd / mm / yyyy) : \\
	
	\noindent\fbox{\begin{minipage}{.5\linewidth}
			The user:\\ \textsuperscript{\tiny Handwrite ``Read and accepted''}
			\vspace{2cm}
		\end{minipage}}
		
	\end{document}