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Formulario SIMPATIZANTE HARRIKADA
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* Indicates required question
IZENA / NOMBRE
*
Your answer
JAIOTEGUNA / FECHA DE NACIMIENTO
*
MM
/
DD
/
YYYY
NAN / DNI
*
Your answer
TELEFONOA / TELEFONO
*
Your answer
E-MAIL
*
Your answer
ORDAINTZEKO MODUA/FORMA DE PAGO
*
BANKU-TRANSFERENTZIA/ TRANSFERENCIA BANCARIA (30€)
KONTU ZENBAKIA/Nº DE CUENTA
*
Your answer
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