Gender

First Name

LastName/FamilyName

C/O

Street

House Number

Swiss Resident

Zip Code

City

Country

Birth Date (DD-MM-YYYY)

Nationality

ID Type

ID Number

Nationality of ID

Private Phone Number

Business Phone Number

Fax Number

Email Address

Repeat Email Address

MSISDN1

Sim Number (Last 4 digits)

Preferred Language

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Registered By

Retailer Name

Retailer ID