First name

Surname

Gender
manwoman

Date of birth

Email

Phone number

Street

House number

Postcode

Residence

Reason for deregistration

Deregistration date (DD-MM-YYYY e.g.:12-04-2018)
Date must not be in the past.

Signature

You need to put your signature. With a desktop computer, you can sign your signature with your mouse in the area below. With a tablet or phone, you can use your finger to sign your signature in the area below.

Note: If you use an incorrect signature, the deregistration will not be valid!

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