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Company name: |
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Legal representative: |
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Function: |
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Tel.: |
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Fax: |
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Mobile phone: |
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E-mail: |
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Company address: |
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Date of constitution of the company: |
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National identification number: |
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Activities of the company: |
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Names and functions of those empowered as executives of the company: |
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Form(s) of collaboration sought (select): |
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Comments: |
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