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Edizioni dell’Orso – Via Urbano Rattazzi, 47 – 15121 Alessandria (Italy)
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NOME / NAME _______________________________________________________________________

COGNOME / SURNAME _______________________________________________________________

ISTITUZIONE / INSTITUTION __________________________________________________________

P. IVA / VAT ________________________________________________________________________

INDIRIZZO / ADDRESS ______________________________________________________________

CAP / ZIP _______________________ CITTÁ / CITY _______________________________________

STATO / COUNTRY __________________________________________________________________

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Carta Numero / Card Number _________________________________________________________

Scadenza / Expiry date ______________________________________________________________

Data / Date ________________________________________________________________________

Firma / Signature ___________________________________________________________________