Country of interest:*

Form of address:* Mr. Mrs.

Last name:*

First name:*

Street:*

ZIP code/City:*

Country:*

Personal phone:*

Business phone:

Cell phone:

E-mail:*

Date of birth:*

Nationality:*

Herewith I agree that my personal data will be saved and processed. Further, I assure that the data stated before is correct. Declaration of consent:*

Herewith I agree that my personal data, as provided by me, may be saved and used by BackWERK for a first orientation with respect o a potential application and will be used in accordance with the statement governing German data privacy law. I also agree that my personal data may be forwarded to third parties only for the aforementioned purpose in compliance with the statement governing data privacy law. BackWERK assures that my personal data will not be used for other purposes, nor will such data be forwarded to any other third parties than BackWERK-partners.

I hereby assure that I was conveniently informed about the importance especially about the intended purpose of the data and that I may revoke my declaration of consent any time with future effect here.

I agree.

I hereby declare that, following careful verification, the given information is true, correct and complete.