Lægeerklæring for 2021 registrering

Tilmelding til kurset Lægeerklæring for 2022 herunder.

E-mail *

Mobil nr.: *

Fornavn: *

Efternavn: *

Adresse: *

Postnr.: *

By: *

Land *

Are you fully recovered from any operation in your medical history? *

Do you take any percription medication? *

Do you take any medicine that influence your ability to drive? *

Do you have full moment of joints, muscles, ligatures *

Yes

Do you wear a denture (prosthesis)? *

Do you have over 6/18 visual sight with or without corrections *

Yes

Are you fully recovered from any emergencies in your medical history? *

Yes

Have you been denied driver's license based on your health/ sight? *

Fødselsdag *

Født i *

Fødested *

Beløb

€

Betalings Methode

Paypal

Billing Zipcode*

Indtast nummer på kortet*

Indtast Udløbsdato*

Kort (CVV) Code*

Navn på kortet*

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Bekræftelseskode*