New loyalty card request form

1 - Personal data

2 - Confirm email

3 - Card issuing

Name:*

Surname:*

Gender:*

Male

Female

Not specified

Phone number:*

Telephone number:

City of residence:*

Postal code:*

Residence address:*

Street number:*

Preferred store:*

Date of birth:*

Discount code:

Consent to the data processing for direct marketing purposes (telephone, sms, mms, email, post)

Consent to the processing of data for profiling purposes (evaluation of preferences, consumption habits, marketing surveys and statistics)

*mandatory fields