Extended Private Connection (VPA) Application Form

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Applicant data

Please note that fields marked * are required

Use this form to apply for an exemption for an extended private connection (VPA).

Initial(s) *

Insert(s)

Last name *

Street name *

House number *

House number addition

Zip code *

Residence *

Email address *

Phone number

The phone number must begin with 0 and consist of 10 digits. Only digits may be entered in this field.