EUBREAST DONATION FORM

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EUBREAST (Italy)

Email *

Last Name (Cognome) *

Name (Nome) *

Company or Preferred Affiliation (Azienda / Ospedale / Clinico)

Type of Donation (Tipo di donazione) *

Date of Birth (Data di nascita') *

YYYY

Place of Birth (Luogo di nascita') *

Street Address (via e numero civico) *

City of residence (Citta' di residenza) *

State / Region of Residence (Provincia di residenza) *

Country of residence (Paese di residenza) *

Postal Code (CAP) *

Telephone number (Numero telefonico) Ex. +393485555555

Personal Tax Code (Codice Fiscale) - required for receipt (necessario per la ricevuta)

Please send me a receipt / Inviatemi la ricevuta *

Yes

I declare to have read and accept the Privacy and Data Processing Policies found on the EUBREAST website /Dichiaro di aver presa visione dell'informativa sull'Privacy e acconsento al trattamento dei dati trovato sul sito EUBREAST. The data submitted on this form will be used to create your fiscal receipt and then maintained in our list of donors. It will also be added to an internal mailing list for occasional updates from the EUBREAST Network (EUBREAST ETS and EUBREAST e.V). *

I consent to the terms listed above

I consent to the terms listed above, but do not wish to receive communications from the EUBREAST Network

I do not consent to any of the above

Required

Payment method (modalita' di Pagamento) *

IBAN - IT 42F0306234210000001998079

Paypal

A copy of your responses will be emailed to the address you provided.

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