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Number Dog Reg. No. Amount Total

First name:

Last name:

Street:

Zip code:

City


Phone:

Fax:

E-mail:

Remarks:

Print  printout and send it by fax, or mark these data  and send it by E-mail.

Zusatzangaben für überweisungen in das Ausland:
Additional data for remittances abroad:

SWIFT-BIC:

Empfänger:
Recipients: