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NAME SURNAME ADDRESS DISTRICT CITY ZIP CODE COUNTRY EMAIL CONFIRM EMAIL	VAT NUMBER TELEPHONE MOBILE PHONE FAX LOGIN PASSWORD CONFIRM PASSWORD *QUALIFICATION ORTHODONTIST GENERAL DENTIST Please include me in the list of certified dentist available in the public website (after the certification)
I declare that I have read the informative (here) according to Art. 13, of the Legislative Decree no. 196/2003 (Italian Personal Data Protection Code) and EU Directive 95/46/EC and I authorize the processing of my data (*):	I'm aware of the penalties provided for in case of false declarations, in compliance with art. 76 of DPR 445/2000 (Italian Law) and I declare that the data here inserted by myself are correct and true. (*):
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