type* corporate private business title  
surname/business name*
name*
gendre m f      
city of birth   date of birth  (dd-mm-yyyy)
nationality
address*
postal/zip code*   town/city*   
country*
region/county/state   state  
vat registration number/social security number*
work tel.   home tel.  
mobile   fax  
email*
password*  confirm*  
interested in* arms jewels  

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