I am hereby requesting a self-disclosure:

required fields are marked with

academic title:
first name:
surname:
date of birth:	jjjj mm tt
gender:	male female
former name(s):

street:
No.:
postal code:		place:
phone:
e-Mail:
former/further address(es):
Zuaddress for service:
ID number:
issue date:

I would like to be informed about the data that is currently stored on me at KSV1870 Information GmbH:

Self-disclosure for presentation

Please send the self-disclosure to the abovementioned home address within 1 week costs including postal charges EUR 29.70 (= EUR 22,00 + 7,70 - cash on delivery, by certified mail, personal acceptance)

Self-disclosure free of charge

In accordance with § 26 of the Data Protection Law paragraph 1 (proof of identity) and paragraph 3 (participation in proceedings) I am hereby requesting transfer of all data stored on me within statutory period (8 weeks). Proof of identity (e.g. passport, official photo ID) is to be presented at delivery.

As an entrepreneur, I am hereby ordering a:

self-disclosure from the KSV1870 Economic Database

Please send the self-disclosure to the abovementioned service address within 8 weeks free of charge.

Place/Date (jjjj.mm.tt):	. .

Further questions?
Please contact our CustomerCareCenter T: 050 1870-1101