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Tand doet van onderstaande aangekruiste categorie( n). Indien ondergetekende weer in het bezit wil komen van n of meer categorie n waarvan hieronder tijdelijk afstand wordt gedaan, dan dient bij de aanvraag daartoe een verklaring van geschiktheid voor de betreffende categorie( n) te worden overgelegd. Persoonsgegevens ondergetekende Burgerservicenr. Naam Voornaam Initialen Adres Postcode Woonplaats Land Geboortedatum Geboorteplaats Houder van het rijbewijs Rijbewijsnummer Afgifteda.

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