Declaration of changed personal data

I, the undersigned:

Name:
postal address:
identity card number/date of birth:

I hereby declare that I am the user of the domain ................................... and that the following data currently in the register have been changed to the above data:

Name:
Postal address:
ID card number/date of birth:

I declare that the information provided correspond to reality.

Date:

Signature of declarant

(If the Declarant certifies the document using the AVDH procedure, there is no need for witnesses or for the document to be signed by hand.)

Witness 1.	Witness 2.
Name:	Name:
Address:	Address:

Signature:	Signature: