CONSUMER REGISTRATION

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NAME

SURNAME

SEX
M F
DATE OF BIRTH

HEIGHT (cm)

WEIGHT(kg)

ADDRESS

POSTAL CODE

CITY

TEL (home)

TEL (office)

MOBILE NUMBER

EMAIL

EMAIL (to confirm)

OCCUPATION

ARE YOU COVERED BY HEALTH INSURANCE?
YES NO
WHAT ARE THE REASONS FOR PARTICIPATING IN THESE CONSUMER TEST?

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