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<p>
<input type="hidden" name="publicid" value="9eba111f6f9537e3efb5c5676f82b65a" />
<input type="hidden" name="name" value="Associazione podologo" />
</p>
<p>
<label>Cognome</label>
<input type="text" value="" name="lastname" required="true" />
</p>
<p>
<label>Nome</label>
<input type="text" value="" name="firstname" required="true" />
</p>
<p>
<label>Telefono</label>
<input type="text" value="" name="phone" required="true" />
</p>
<p>
<label>Email</label>
<input type="text" value="" name="email" required="true" />
</p>
<p>
<label>Codice fiscale</label>
<input type="text" value="" name="cf_xru_1255" />
</p>
<p>
<label>Luogo di nascita</label>
<input type="text" value="" name="cf_xru_1254" required="true" />
</p>
<p>
<label>Data di nascita</label>
<input type="date" value="" name="cf_xru_1253" required="true" />
</p>
<input type="hidden" value="Web Site" name="leadsource" />
<input type="hidden" value="Not Contacted" name="leadstatus" />
<p>
<label>Luogo di Residenza</label>
<input type="text" value="" name="city" required="true" />
</p>
<p>
<label>Indirizzo</label>
<input type="text" value="" name="lane" />
</p>
<p>
<label>CAP</label>
<input type="text" value="" name="code" />
</p>
<p>
<label>N. ISCRIZIONE Albo Professionale</label>
<input type="text" value="" name="cf_xru_1256" required="true" />
</p>
<p>
<label>Data iscrizione Albo Professionale</label>
<input type="date" value="" name="cf_xru_1258" required="true" />
</p>
<p>
<label>CITTA' ISCRIZIONE Albo Professionale</label>
<input type="text" value="" name="cf_xru_1257" required="true" />
</p>
<p>I suoi dati saranno trattati secondo quanto indicato nella nostra <a href="https://www.associazionepodologi.it/wp-content/uploads/2021/04/privacy-aip.docx" target="_blank">Informativa privacy</a></p>
<p>
<label>ACCETTO PRIVACY</label>
<select name="gdpr_personal_data" required="true">
<option value="">--Prego Selezionare--</option>
<option value="off">No</option>
<option value="on" >Sì</option>
</select>
</p>
<input type="hidden" value="$(general : (__VteMeta__) date_d_m_Y) $(general : (__VteMeta__) time)" name="gdpr_personal_data_checkedtime" />
<input type="hidden" value="$(general : (__VteMeta__) clientip)" name="gdpr_personal_data_remote_addr" />
<p>
<input type="submit" value="Submit" />
</p>
</form>
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