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Application for loyalty card

Entity:
Card:
marked with "*" - information required
mark "" which information you want to indicate in receipt
*Name:
*Surname:
*Postal address to send the card:
*Tel: +371
*E-mail:
Address:
Personal code:
I am familiar with the Card Receipt and Usage Provisions.*
*
Image CAPTCHA
Enter the characters shown in the image.
Please indicate all requested information to be used for agreement preperation.
* Name:
*Surname:
*Personal code:
*Address:
*Postal address:
*IBAN:
*SWIFT/BIC:
*Type of card:
*Desired monthly limit:
*Card amount:
*Tel.: +371
*E-mail:
I am familiar with the Card Receipt and Usage Provisions.*
*
Image CAPTCHA
Enter the characters shown in the image.
Please indicate all requested information to be used for agreement preperation.
Company’s name:
VAT Nr.:
VAT payer:
Company’s address:
Postal address to
send the card:
Card amount:
Contact person
Name:
Surname:
Tel: +371
E-mail:
I am familiar with the Card Receipt and Usage Provisions.*
*
Image CAPTCHA
Enter the characters shown in the image.
Please indicate all requested information to be used for agreement preperation.
Company’s title:
VAT Nr.:
numurs:
PVN maksātājs:
Company’s address:
Postal address to
send the card:
IBAN:
SWIFT/BIC:
Type of card
Desired monthly limit:
Card amount:
Contact
Name:
Surname:
Tel: +371
E-mail:
I am familiar with the Card Receipt and Usage Provisions.*
*
Image CAPTCHA
Enter the characters shown in the image.