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Voornaam (First name)
*
Your answer
Achternaam (Surname)
*
Your answer
Adres (Address)
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Your answer
Postcode (Postal code)
*
Your answer
Woonplaats (City)
*
Your answer
Land (Country)
*
Your answer
Email
*
Your answer
Rekeningnummer (IBAN Bank account)
*
Your answer
BIC (For non-Dutch banks)
Your answer
Bedrag (Amount)
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€25
€50
€75
€100
Other:
Frequentie (Frequence)
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Eenmalig (Once)
Jaarlijks (Annually)
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