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Book a lesson:
Name*
First name*
Parents name and first name (for the miner)
Street* - Number* -
Postbox
Postal Code* - City* -
Country*
GSM*
Email*
Date of birth* / /
Language* FR  EN  NL  Other 

Session*:

January - march 2018
3 sessions (of your choice, valid for 1 year)
One course
Card 10 or 20 units



I wish to receive a discount :

Promotion code :

I'm sponsor by (only if you are a new student at PDB) :

Name and first name :

I know Pole Dance Belgium thanks to *:

google
facebook
the press
the lesson establishment
a friend, an acquaintance
other


I wish an invoice with this informations:

Name*
Address*
VAT number*


Comment

I have read and I accept the sales general conditions.



Attention ! If you to the registration for someone else, don't note your personal informations but those of the person register to the lesson.