Declaration of authenticity of personal data

I, the undersigned:

name:
postal address:

I declare that:

my identity card number/date of birth:
my nationality:

I declare that the information provided they correspond to reality.

Date:

Declarant's signature

(If the Declarant certifies the document using digital signature, 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: