*** Filling this questionnaire expressly agrees that Diper, inc. use my email address to contact me and answer my query.

In accordance with the Data Protection Act, I agree that my personal data provided on this form will be included by Diper, inc. in an electronic file which is responsible in order to attend the consultation here will raise. I also consent to Diper inc. use the e-mail address that makes it easier to respond to my query.

Be informed of further declare my ability to exercise their rights of access, rectification, cancellation and opposition by writing to Diper, inc. accompanied by a photocopy of my passport.