Reservation form for natural persons

Family name
First name
Date of birth (dd-mm-yyyy)
Place of birth
Nationality

Residence
Address
City
State/Region
Country
Phone
Fax
E-mail

On the conditions pointed out at www.avatar.st, web site, I ask to underwrite the debenture loan called "Avatar Superprofit Extension"
for the amount of

The underwriting price will be deposited through:
bank

at the following bank details:
country
cod		 check
digit		 cin abi cab account num.