The undersigned *

DOB*

(dd/mm/yyyy) *

Resident in *

Address *

E-mail*

Claiming to be a parent or Legal guardian of the child (Name and Surname)*

DECLARES

that they wear an ocular prosthesis applied by Dalpasso s.r.l. with registered office in Reggio Emilia, via Turri n. 10 *
YESNO

that they are aware of the legal consequences of providing false data or information *
YESNO

that they have been informed by Dalpasso s.r.l. regarding the standards that govern the processing of sensitive data pursuant to Legislative Decree 196/2003 *
YESNO

holding harmless Dalpasso s.r.l. from all responsibility in relation to this request *
YESNO

REQUESTS

a copy of the photographic digital images of the mentioned minor taken and stored in the magnetic archives of the company Dalpasso s.r.l. to be sent to them

date on which photographs were taken *

For that purpose chooses the following support for the requested images:
CD Rom to be sent by post with costs charged to the addressee *

Email to be sent to the following address: *

I will provide a photocopy of a form of identification as soon as possible via:*
FaxE-mailServizio postale

PRIVACY

The undersigned acknowledges the information notice provided pursuant to Art. 13 of Legislative Decree 196/2003 and provides consent for their personal data to be processed for the aims indicated and to be subject to communication to the parties and for the purposes stated.
I ACCEPT