*Name:
*Surname:
Company Name:
*E-mail:
*Address:
*Country:
*Cap:
*Region:
-- Estero --
AG
AL
AN
AO
AP
AQ
AR
AT
AV
BA
BG
BI
BL
BN
BO
BR
BS
BZ
CA
CB
CE
CH
CI
CL
CN
CO
CR
CS
CT
CZ
EN
FC
FE
FG
FI
FR
GE
GO
GR
IM
IS
KR
LC
LE
LI
LO
LT
LU
MC
ME
MI
MN
MO
MS
MT
NA
NO
NU
OG
OR
OT
PA
PC
PD
PE
PG
PI
PN
PO
PR
PT
PU
PV
PZ
RA
RC
RE
RG
RI
RM
RN
RO
SA
SI
SO
SP
SR
SS
SV
TA
TE
TN
TO
TP
TR
TS
TV
UD
VA
VB
VC
VE
VI
VR
VS
VT
VV
*Nation:
*VAT or Tax Identification:
Afghanistan Albania Algeria Andorra Angola Anguilla Antartide Antigua e Barbuda Antille Olandesi Arabia Saudita Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrein Bangladesh Barbados Belgio Belize Benin Bermuda Bhutan Bielorussia Bolivia Bosnia Erzegovina Botswana Brasile Brunei Darussalam Bulgaria Burkina Faso Burundi Cambogia Camerun Canada Capo Verde Christmas Island Ciad Cile Cina Cipro Cocos (Keeling) Islands Colombia Comore Congo Congo,Rep. Democratica Corea del Nord Corea del Sud Costa d'Avorio Costa Rica Croazia Cuba Danimarca Dominica Ecuador Egitto EIRE El Salvador Emirati Arabi Uniti Eritrea Estonia Etiopia Falkland Islands (Malvinas) Figi Filippine Finlandia Francia Gabon Gambia Georgia Germania Ghana Giamaica Giappone Gibilterra Gibuti Giordania Gran Bretagna Grecia Grenada Groenlandia Guadalupa Guam Guatemala Guiana Francese Guinea Guinea Equatoriale Guinea-Bissau Guyana Haiti Holy See (Vatican City State) Honduras Hong Kong India Indonesia Iran Iraq Islanda Isola Bouvet Isola di Norfolk Isole Cayman Isole di Cook Isole Faroe Isole Heard e McDonald Isole Maldive Isole Marianne del Nord Isole Marshall Isole Minor Outlying, USA Isole Solomone Isole Turks e Caicos Isole Vergini, GB Isole Vergini, USA Israele Italia Kazakistan Kenya Kirgizistan Kiribati Kuwait Laos Lesotho Lettonia Libano Liberia Libia Liechtenstein Lituania Lussemburgo Macao Macedonia Madagascar Malawi Malaysia Mali Malta Marocco Martinica Mauritania Mauritius Mayotte Mexico Micronesia Moldova, Republic of Monaco Mongolia Montserrat Mozambique Myanmar Namibia Nauru Nepal Nicaragua Niger Nigeria Niue Norvegia Nuova Caledonia Nuova Guinea Nuova Zelanda Oceano Indiano, territorio britannico Oman Paesi Bassi Pakistan Palau Panama Paraguay Peru Pitcairn Polinesia Francese Polonia Porto Rico Portogallo Qatar Repubblica Ceca Repubblica Centrafricana Repubblica Dominicana Réunion Romania Russia Rwanda Sahara Occidentale Saint Kitts e Nevis Saint Pierre e Miquelon Saint Vincent e le Grenadine Samoa Samoa Americane San Marino Sant'Elena Santa Lucia Sao Tome e Principe Senegal Serbia e Montenegro Seychelles Sierra Leone Singapore Siria Slovacchia Slovenia Somalia Spagna Sri Lanka Sud Africa Sud Georgia e Isole Sandwich del Sud Sudan Suriname Svalbard e Jan Mayen Svezia Svizzera Swaziland Tagikistan Taiwan Tanzania Territori Francesi del Sud Territori Palestinesi Thailand Timor Est Togo Tokelau Tonga Trinidad e Tobago Tunisia Turchia Turkmenistan Tuvalu Ucraina Uganda Ungheria Uruguay USA Uzbekistan Vanuatu Venezuela Vietnam Wallis e Futuna Yemen Zambia Zimbabwe
*Telephone:
Given that 1. has already carefully read and understood in all its parts the information provided in accordance to Art. 13 of Legislative Decree 196/2003, 2. is perfectly aware of the rights according to Art. 7 of Legislative Decree 196/2003, 3. acts freely and without any influence or psychological pressure; now, therefore expresses his/her consent to the gathering and processing of his/her own personal data and, if any, sensitive data necessary for the purposes outlined in paragraph a) of the above-mentioned information note.
(Click to sign)
'Direct Marketing' consent (optional) The undersigned – Company, with the below signature, also expresses the specific and explicit consent to the use of data for the purposes specified in paragraph b) of the information note and therefore agrees to receive advertising material/communications, such as brochures, invitations, newsletters, via mail, e-mail, fax, sms, mms and so forth. It is understood that the undersigned has the right to revoke this consent at any time by contacting the responsible party.
(Click to sign)
Enter the characters shown in the image below: