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Formulario SIMPATIZANTE HARRIKADA
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IZENA / NOMBRE *
JAIOTEGUNA / FECHA DE NACIMIENTO *
MM
/
DD
/
YYYY
NAN / DNI *
TELEFONOA / TELEFONO *
E-MAIL *
ORDAINTZEKO MODUA/FORMA DE PAGO *
KONTU ZENBAKIA/Nº DE CUENTA *
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