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Tel. +39 049 5290513 Fax +39 049 7962509 www.deminici.it

Nome / Surname / Prenom / Vorname ______________________________________________

Cognome / Name / Nom / Name ___________________________________________________

Via / Street / Rue / Strasse _________________________________________________________

Città / City / Ville / Stadt __________________________________________________________

Stato / State _________________________________________________________________________

Codice Postale / Postal code / Boite postale / Postleizahl _________________________________

Telefono / Telephone / Telefon _____________________________________________________

Telefax _________________________________________________________________________

Email __________________________________________________________________________

Cod. Fiscale o Partita I.V.A. _____________________________________________________

Tipo e modello vettura / Car type and model /

Type et modèle de la voiture / Autotyp _________________________________________________

Anno di prima immatricolazione / Year of first immatriculation /

Année de mise en circulation / Jahrgang der Erstzulassung __________________________________

Numero di telaio / Chassis number / Numeros de chassis / Fahrgestellnummer __________________

Colore vettura / Colour of car / Couleur de la voiture / Autofarbe ____________________________

Guida a destra / Right-hand drive / Conduite à droite / Rechtslenkung ________________________

Guida a sinistra / Left-hand drive / Conduite à gauche / Linkslenkung _________________________

Tetto aperto/ Tetto chiuso/ Cabriolet __________________________________________________