XS2 Terms & Conditions IE

                               

Definitions

 

IDNA B.V. is the service provider of the XS2 dating network and websites.

‘The Service Provider’, ‘we’, ‘us’ and ‘our’ refers to IDNA B.V. and/or its employees, its affiliated companies and/or parent companies

‘Partner’ refers to the company Meta-4 Group with which we have entered into a cooperation in order to provide you with the XS2 dating websites.

‘’XS2’, ‘Website’ or ‘Service’ refers to the XS2 dating network and websites (including but not limited to the XS2SX, XS2Date, SX2Flirt, XS2Friends and XS2Fun websites) and all of its functionalities.

‘User’, ‘you’ and ‘your’ refers to the user of the Service.

 ‘Terms’ refers to the Terms and Conditions, as set forth herein.

‘Content’ includes but is not limited to text, links, images, photographs and recordings.

 

IDNA B.V. 

Stadhouderskade 85
1073 AT Amsterdam
The Netherlands


Business registration number: Düsseldorf: 34377401
VAT number: NL8219.00.122.B01

Legal Agreement

 

Before using the Service, please read these terms and conditions carefully. These terms constitute a legal agreement (“Agreement”) between you and us. In order to use the Service you must agree to the terms that are set out below. By registering for the Service, visiting the Website or making use of the Service you explicitly agree to be bound by the terms of this Agreement, including any amendments made by us that are published herein.

 

The terms of this Agreement are set forth below, and also include our Privacy Policy which you are required to read. This Agreement is subject to change by the Service Provider in its sole discretion at any time, by posting the amended terms in the ‘about us’ section of the Website. Continued use of the Service after any such amendments shall constitute your consent to such changes.

 

In case you do not agree to these terms or our privacy policy, or if you are under 18 years of age, please do not use the Service.

 

We would like to draw your attention to the following important provisions:

 

  1. XS2 is an adult dating network which is not directed at minors, and if you are under 18 years of age you must not use our Service.

 

  1. Please choose carefully the information you post on or through the Service and that you provide to other users. Your XS2 profile may not include any form of prohibited content, as outlined in the Code of Conduct below. Despite this prohibition, information, materials, products or services provided by other users may, in whole or in part, be unauthorized, impermissible or otherwise violate these terms, and we assume no responsibility or liability for this material. If you become aware of misuse of the Service by any person, please notify us by reporting the misuse via the application or sending an e-mail to info.ie@xs2date.com.

 

  1. WE DO NOT CONDUCT BACKGROUND CHECKS OR OTHERWISE SCREEN USERS OR USER’S PROFILES IN ANY WAY. You are responsible for all of your interaction with other users and you acknowledge that we have no liability in respect of other users of the Service. We do not warrant and we are not responsible for ensuring that other users are in compliance with these Terms. You must take all necessary precautions when communicating with or meeting individuals through this Service.

 

  1. The paid subscription automatically renews for the period and price that you signed up to. You can terminate your subscription to the Service at any time by sending a text message containing the word STOP to 57097, or by contacting the Customer Care Center on the following telephone number: 019079901, or via email: info.ie@xs2date.com.

 

  1. Description of the Service.

 

XS2 user receive weekly dating tips and notifications. XS2 is a dating network for adults only. The Service is available as a desktop and as a mobile version. The Service offers a way to make contact with other people by sending messages or sending a ‘tease’ to another user (the other user receives a notification that someone has shown interest). Users have the possibility to establish a profile in which they can describe their interests, physical characteristics and upload pictures of themselves. Users can establish a ‘hotlist’ in which they collect profiles of other users of their interest, and they can block users from which they do not want to receive messages or teases. The Service offers a search functionality whereby users can perform searches based on interests, physical characteristics or the location of other users.

 

‘Sneak preview’ version

 

Most of the functionalities of the Service can only be used after you have subscribed. However, you may be offered a ‘sneak preview’ of the Service free of charge, whereby you can visit and view the Website and perform a limited amount of actions for a limited amount of time: the user of a sneak preview can browse a limited amount of profiles, see a limited amount of messages and send a limited amount of teases.

 

Virtual Profiles

 

In order to encourage interaction on the Website, for entertainment purposes and in order to enable us to ensure our Service is operated properly by testing the features and functionalities and to research our Service, we may from time to time create profiles which are created, maintained and managed on behalf of XS2 (‘Virtual Profiles’). Virtual Profiles may be managed by a digital actor or send computer generated messages to other users of the Service. For example, the Virtual Profile may provide an electronic introduction to features and functionalities of the Website. The communication by Virtual Profiles may take the form of any communication currently available on the Website.

 

By using the Service, you acknowledge and accept that some of the profiles displayed in the Website are Virtual Profiles which are not actually users of the Service. You further acknowledge that any information or pictures displayed to you via the Virtual Profiles does not relate to an actual person but has been included for the above mentioned purposes. If you respond to, or initiate contact with Virtual Profiles you acknowledge and understand that any response or exchange between the Virtual Profile and you is solely for entertainment purposes, and will not result in a physical meeting.

 

Displaying your profile on ‘IDNA B.V  Websites’

 

By signing up for the Service and establishing a profile for XS2, you acknowledge and agree that your XS2 profile may be displayed on all websites belonging to the XS2 Network (including but not limited to the XS2SX, XS2Date, XS2Flirt, XS2Friends and XS2Fun websites) and other dating websites owned or operated by us (‘Other IDNA B.V Websites’). Users of the XS2 Network and Other [IDNA B.V] Websites can view your profile and contact you. The profiles from users of the XS2 Network and Other IDNA B.V Websites can also be displayed in the Website and you can interact with those users  in case you have subscribed to XS2.

 

User profiles from Partner Websites

 

Certain profiles displayed in the Website may be from users who did not sign up for XS2, but for similar dating websites owned or operated by our Partner (‘Partner Websites’). You can see the profiles from these users of Partner Websites and interact with the users from the Partner Websites in case you have subscribed to XS2. Your profile will not be displayed on the Partner Websites so these users from Partner Websites cannot initiate contact with you. Only in case you initiate contact with a user from one of the Partner Websites will your profile be shown to this user.

 

  1. Eligibility requirements.

 

The application is not intended for individuals under 18 years of age or individuals who are married. If you are under 18 years of age or married, you are prohibited from using the application and you may not access any features that allow you to provide information to us or communicate and share information with other users. By visiting and/or using the Website, you represent and warrant that you are at least 18 years of age and are not married. You also represent and warrant that you have never been convicted of an indictable offence and that you are not required to register as a sex offender with any governmental entity. Your profile may be deleted, and your subscription may be terminated without warning, if we believe that you have violated any of these warranties or representations.

 

  1. Subscription and billing.

 

In case you have subscribed to the Website, the applicable subscription fees are: EUR7.50 per week, inclusive of VAT.

 

The fees for the Service will be charged via the telephone bill of your mobile network provider if you have a monthly contract or via a deduction from your credit if you have a pay-as-you-go plan. Separate mobile network provider text message/WAP/GPRS/UMTS fees or download charges may apply.

 

All fees, including fees for existing subscriptions, are subject to change upon notice from us. We will provide you with reasonable notice of such changes. If you do not accept the new fees (which will never be applied retrospectively), you may cancel your contract with us with immediate effect.

 

In the event of invoicing by a third party (such as Payforit), the payment terms of that third party will apply.

 

  1. Personal, non-commercial usage.

 

You are allowed to access and use the Website for your personal, non-commercial use. You access to content posted on the Website is for your personal use only. You may not authorise others to use your account, and you must not assign or otherwise transfer your account to any other person or entity.

 

You are solely responsible for your own actions and those of anyone using your account. You assume all liability regarding the information and content that you post, transmit, publish, or otherwise make available through the Website, and for your interactions with other users of the Website.

 

  1. Code of Conduct.

 

By visiting and/or using the Website, you agree to the following Code of Conduct:

 

5.1. You will keep all information provided to you through the Website as private and confidential and will not give such information to anyone without the permission of the person who provided it to you.

 

5.2 You will not post or otherwise distribute messages, pictures or recordings or use the Website in any way which it violates, plagiarizes or infringes upon the rights of any third party, including but not limited to any copyright or trade-mark law, privacy or other personal or proprietary rights, including other intellectual property rights; or is fraudulent, misleading or otherwise unlawful or violates any law. 

 

5.3. You will not use the Service to engage in any form of harassment or offensive behaviour, including but not limited to the posting of communications, pictures, videos or audio recordings which contain libellous, slanderous, abusive or defamatory statements, or racist, pornographic, obscene, or offensive language or images.

 

5.4. You will not publicly post information that poses or creates a privacy or security risk to any person.

 

5.5. You will not post content that constitutes or promotes an illegal or unauthorized copy of another person’s copyrighted work.

 

5.6. You will not post content that promotes or furthers any criminal activity or enterprise or provides instructional information about illegal activities.

 

5.7 You will not forward chain letters through the Website; you will not use the Website to distribute, promote or otherwise publish any material containing any solicitation for funds, advertising or solicitation for goods or service; you will not use the Website to distribute or up load any virus, Trojan horses or do anything else that might cause harm to the Website, our systems or to other users' systems in any way.

 

5.8 You will not impersonate or misrepresent your association with any person or entity; you will not forge or otherwise seek to conceal or misrepresent the origin of any content provided by you.

 

5.9. You will use the Website in a manner consistent with all applicable laws and regulations.

 

510 You will not copy any ideas, features, functions or graphics of the Website or launch an automated program or script, including but not limited to bots, viruses or worms, web spider or crawlers or any similar program which may impair the operation of the Website.

 

5.11 You will not send spam or unsolicited messages in violation of applicable laws, send any material containing software viruses, worms, Trojan horses or other harmful computer codes, files, scripts or programs or otherwise interfere with the integrity of performance of the Website.

 

  1. Information provided by you.

 

6.1 You agree to provide current, complete and accurate information about yourself when requested by us to do so.

 

6.2 You will maintain and update information regarding user as required to keep it current, complete and accurate. All information that we request and you provide on original registration for the Service and all updates thereto and all information that you provide in your profile including but not limited to copyrighted content, name and likeness and photographs, are referred to as ‘user registration data’.

 

6.3 You automatically assign to us all rights, title and interest in your user registration data and grant us an irrevocable royalty-free, non-exclusive, transferable, perpetual and worldwide license to use, view, copy, adapt, modify, reproduce, perform, display, publish, promote and distribute such user registration data. You waive any moral or potential infringement rights you may have in any such information or content included in you user registration data. Please note that we may use any of your content, including your photographs, for the purposes of publicity and advertising. If you do not wish us to do this, please contact us. You can find further information on how we use your information in our Privacy Policy.

 

6.4 You acknowledge and agree that you are solely responsible for all content that you make available through the Service. Accordingly, you represent and warrant that (1) you either are the sole and exclusive owner of content that you make available through the Service or you have all rights, licenses consent and releases that are necessary for you to make the content available through the Service and (2) that your posting, uploading, submission, publication or transmission of such content will not infringe upon or violate the copyright, trademark, patent or other intellectual property rights or rights or privacy or publicity of any third party or violate any applicable law or regulation.

 

  1. User registration data.

 

Upon registration, including your provision of registration data, you will create an account name and password. Upon subscription, we will send you an email with your credentials. Please make sure you store this email, as it will be sent to you only once. Your account is private and may not be used by anyone else. You are entirely responsible for maintaining the confidentiality of your password and you are allowed to change your password by following instructions in the Website. You will be entirely responsible for all usage of your user account and/or user name, whether authorized or not authorized by you. You agree to immediately notify us of any unauthorized use or your user account, user name or password or any other breach of security known to you. You agree that your password and account may not be transferred or sold to another party.

 

  1. Access to your account.

 

To ensure that we are able to provide the Service, respond to customer needs, and comply with laws, you hereby consent to us being able to access your account and records on a case-by-case basis to investigate complaints or other allegations or suspected abuse. Without limiting the foregoing, we also reserve the right to access, read, preserve, and disclose any information as we reasonably believe is necessary to (i) satisfy any applicable law, regulation, legal process or governmental request, (ii) enforce these terms, including investigation of potential violations hereof, (iii) detect, prevent, or otherwise address fraud, security or technical issues, (iv) respond to user support requests, or (v) protect the rights, property or safety of XS2, its users and the public.

 

  1. Rejection or removal of content.

 

We reserve the right, but are not obligated to monitor all advertisements, public postings and messages to ensure that they are in conformity with these terms, in particular with the Code of Conduct. We reserve the right, at our sole discretion, to reject, refuse to post, delete, move or edit any posting, messages or materials, including without limitation user profiles, accounts, public postings and messages, that we deem to violate the Code of Conduct set out above or seem to be otherwise unacceptable or not in accordance with these terms. You shall remain solely responsible for the content of profiles, public postings, messages and other materials you may upload and/or display in connection to the Service or other users. You guarantee that the material or messages posted by you do not infringe the rights of third parties and you hereby grant us a royalty-free, non-exclusive, transferable, perpetual and worldwide license to use, reproduce and disclose at the discretion of the Service Provider the material placed and/or disclosed by you via the Service. 

  1. Suspension and termination of access to Service.

 

We may in our sole discretion suspend or terminate your access to all or part of the Service at any time, without notice and for any reason, including the breach of these terms. Without limiting the foregoing, any fraudulent, abusive, or otherwise illegal activity which may affect the enjoyment of the Service by others may be grounds for suspension or termination of your access to all or part of the Service.

 

  1. Termination of subscription.

 

11.1. You can terminate your subscription to the Service at any time by sending a text message containing the word STOP to 57097, or by contacting the Customer Care Center on the following telephone number: 019079901, or via email: info.ie@xs2date.com.

 

11.2. When you terminate your subscription, or if we suspend or terminate your subscription pursuant to Section 10, the auto-renewable subscription will stop from the next recurring fee. You will have access to the Service and your account until your last payment expires. Note that cancelling your subscription will not retroactively refund subscription payments, and previously charged subscription fees will not be pro-rated based on cancellation date.

 

11.3. When your subscription is terminated or suspended, your profile will remain visible to other users. Only if you delete your account, your profile will not be visible anymore to other users. If you want your profile or any information from your profile to be deleted, then you can contact us and request the deletion of such information or your entire profile. You can contact us via phone 019079901 or via email: info.ie@xs2date.com. For more information on this subject, please see our Privacy Policy.

 

  1. Cancellation.

 

You will have a period of 14 days in which to cancel your contract with us unless you have asked us to supply the Service to you immediately and have acknowledged that this cancellation period will not apply. To cancel your contract within the 14 days you can use the model cancellation form (attached to these Terms as Annex I) or you can contact us by sending an email to info.ie@xs2date.com or telephone us on 019079901 (free of charge).

Note: When you contact us via email or telephone or by filling in and sending us the cancellation form, please mention your mobile phone number. This enables us to process your cancellation.

 

  1. Notifications.

 

We may provide you with notifications by e-mail or notifications sent to the inbox of your XS2 profile. Notice shall be deemed given 24 hours after an e-mail or notification is sent.

 

  1. Privacy Policy.

 

Our Privacy Policy, as it may be updated from time to time, available on the Website, is incorporated into these terms by this reference. We may amend the Privacy Policy from time to time pursuant as described in the Preamble above.

 

  1. External links.

 

The Service may contain links to internet sites and advertisements (‘external links’). You acknowledge that we are not responsible for, and have no liability as a result of, the availability of external links or their content.


  1. Indemnification.

 

You agree to indemnify, defend and hold harmless the Service Provider  and its holding companies, members, subsidiaries, affiliated companies, service providers, contractors, agents, representatives, licensors, managers, officers, directors, shareholders and employees in connection with any claim, lawsuit, action, demand or other proceeding filed by a third party caused by, as a result of or in connection with your (i) use of the Service, (ii) infringement of the Privacy Policy or this Agreement or (iii) breaches of any law, regulation or the rights of any third party. You shall pay any and all costs, damages and expenses, including but not limited to the reasonable legal fees incurred and the costs charged to or otherwise incurred by the Service Provider  in connection with or arising from such a claim, lawsuit, action, demand or other proceeding. If you have a dispute with another user, you agree to release the Service Provider , its affiliates, its parent, and their officers, directors, employees, suppliers, consultants and agents from any and all claims, liabilities, damages and costs (including but not limited to reasonable legal fees) arising out of or in connection with the dispute.

 

  1. DISCLAIMER OF WARRANTIES.

 

YOU EXPRESSLY ACKNOWLEDGE AND AGREE THAT USE OF THE WEBSITE AND THE SERVICE IS AT YOUR SOLE RISK AND THAT THE ENTIRE RISK AS TO SATISFACTORY QUALITY, PERFORMANCE, ACCURACY AND EFFORT IS WITH YOU. TO THE MAXIMUM EXTENT PERMITTED BY APPLICABLE LAW, THE WEBSITE AND THE SERVICE ("SERVICES") ARE PROVIDED "AS IS" AND “AS AVAILABLE”, WITH ALL FAULTS AND WITHOUT WARRANTY OF ANY KIND, AND THE SERVICE PROVIDER  HEREBY DISCLAIMS ALL WARRANTIES AND CONDITIONS WITH RESPECT TO THE WEBSITE AND THE SERVICE, EITHER EXPRESS, IMPLIED OR STATUTORY, INCLUDING, BUT NOT LIMITED TO, THE IMPLIED WARRANTIES AND/OR CONDITIONS OF MERCHANTABILITY, OF SATISFACTORY QUALITY, OF FITNESS FOR A PARTICULAR PURPOSE, OF ACCURACY, OF QUIET ENJOYMENT, AND NON-INFRINGEMENT OF THIRD PARTY RIGHTS. THE SERVICE PROVIDER DOES NOT WARRANT AGAINST INTERFERENCE WITH YOUR ENJOYMENT OF THE WEBSITE OR SERVICE, THAT THE FUNCTIONS CONTAINED IN, OR SERVICES PERFORMED OR PROVIDED BY, THE WEBSITE OR SERVICE WILL MEET YOUR REQUIREMENTS, THAT THE OPERATION OF THE WEBSITE OR SERVICE WILL BE UNINTERRUPTED OR ERROR-FREE, OR THAT DEFECTS IN THE WEBSITE OR SERVICE WILL BE CORRECTED. NO ORAL OR WRITTEN INFORMATION OR ADVICE GIVEN BY THE SERVICE PROVIDER OR ITS AUTHORIZED REPRESENTATIVE SHALL CREATE A WARRANTY.  SOME JURISDICTIONS DO NOT ALLOW THE EXCLUSION OF IMPLIED WARRANTIES OR LIMITATIONS ON APPLICABLE STATUTORY RIGHTS OF A CONSUMER, SO THE ABOVE EXCLUSION AND LIMITATIONS MAY NOT APPLY TO YOU.

 

We assume no responsibility for availability (or lack thereof), timeliness (or lack thereof), deletions, misdeliveries, or failures to store any user communications or personalization settings. In particular, but not by way of limitation, we may delete e-mail or user accounts or the information therein if the account is inactive for more 2 years and the user of the account is not subscribed. You will be solely responsible for any damages to your DESKTOP OR mobile device system or loss of data that results from the download of such material and/or data.

 

You expressly understand and agree that any person you may exchange information with or meet with is done at your own risk and that we make no representations that individuals using the Service are whom they purport to be. We do not conduct background checks or otherwise screen users or user’s profiles in any way. We are not responsible for the accuracy or reliability of any statement made by any users.  You acknowledge that there are security, privacy and confidentiality risks inherent in wireless communications and technology and we do not make any assurances or warranties relating to such risks.

 

  1. LIMITATION OF LIABILITY.

NOTHING IN THIS AGREEMENT or IN THE PRIVACY POLICY SHALL EXCLUDE OR LIMIT OUR LIABILITY FOR DEATH OR PERSONAL INJURY AS A RESULT OF OUR NEGLIGENCE, Nor any other liabilIty which cannot be excluded or limited by law.

NOTHING IN THIS AGREEMENT, INCLUDing BUT NOT LIMITED TO ARTICLE 14 ABOVE, OR IN THE PRIVACY POLICY SHALL AFFECT YOUR STATUTORY RIGHTS AS A CONSUMER.

 

To the fullest extent permitted by law, THE SERVICE PROVIDER (including its officers, employees and agents) expressly excludes conditions, representations, warranties and other terms which might otherwise be implied by statute, common law or the law of equity; and To the fullest extent permitted by law, IN NO EVENT SHALL THE SERVICE PROVIDER BE LIABLE FOR PERSONAL INJURY, OR ANY INCIDENTAL, SPECIAL, INDIRECT OR CONSEQUENTIAL DAMAGES WHATSOEVER, INCLUDING, WITHOUT LIMITATION, DAMAGES FOR LOSS OF PROFITS, LOSS OF DATA, BUSINESS INTERRUPTION OR ANY OTHER COMMERCIAL DAMAGES OR LOSSES, ARISING OUT OF OR RELATED TO YOUR USE OR INABILITY TO USE THE WEBSITE OR SERVICE, HOWEVER CAUSED, REGARDLESS OF THE THEORY OF LIABILITY (CONTRACT, TORT OR OTHERWISE) AND EVEN IF the Service Provider  HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES. SOME JURISDICTIONS DO NOT ALLOW THE LIMITATION OF LIABILITY FOR PERSONAL INJURY, OR OF INCIDENTAL OR CONSEQUENTIAL DAMAGES, SO THIS LIMITATION MAY NOT APPLY TO YOU.  

Without limiting the foregoing, we will not be liable for indirect damages arising out of or in connection with (i) the use of the Service or the inability to use the Service, (ii) the cost of obtaining substitute goods and/or service resulting from any transaction entered into through the Service, (iii) loss of, unauthorized access to or alteration of your data transmissions, (iv) statements by any third party or conduct of any third party using the Service (v)  physical damages, bodily injury or emotional distress arising out of or in connection with the use of the Service, including without limitation damages arising out of your communications or interactions with any other user of the Service or anyone you meet via the Service, or (vi) any other matter relating to the Service.

 

IN ANY CIRCUMSTANCES WHERE THE SERVICE PROVIDER (including its officers, employees and agents) IS HELD TO BE LIABLE TO YOU, THIS LIABILITY SHALL BE LIMITED TO THE AMOUNT PAID BY YOU FOR THE USE OF THE SERVICE, OR, IF YOU HAVE NOT PAID THE SERVICE PROVIDER FOR THE USE OF THE SERVICE, THE AMOUNT OF £25.00 OR ITS EQUIVALENT.

 

  1. Reservation of rights.

 

You acknowledge that you are allowed to access and use the Website for your personal, non-commercial use only and you will have no rights to make any commercial use of the Service without our prior written consent. We own all right, title and interest, including all intellectual property rights, in and to the Website, its content, and the Service.

 

  1. Applicable law.

 

You agree that any dispute, controversy, or claim arising out of, relating to, or in connection with these this Agreement or the Privacy Policy or your use of the Service will be governed by and construed in accordance with English law, without regard to or application of its conflict of law provisions, and that any dispute arising out of or relating to this Agreement, the Service or the Privacy Policy will be subject to the exclusive jurisdiction and venue of the English courts.

21. Injunctions.

 

You acknowledge and agree that any violation of this Agreement may cause the Service Provider  irreparable harm, and therefore agree that the Service Provider  will be entitled to seek extraordinary relief in court, including but not limited to temporary restraining orders, preliminary injunctions and permanent injunctions without the necessity of posting a bond or other security, in addition to and without prejudice to any other rights or remedies that the Service Provider  may have for a breach of this Agreement.

 

  1. Rights of Third Parties.

 

 This Agreement does not create any rights under the Contracts (Rights of Third Parties) Act 1999 which are enforceable by any person who is not a party to this Agreement.

 

  1. Miscellaneous.

 

Unless otherwise explicitly stated, the terms of this Agreement will survive termination of your registration to the Service. Any failure of the Service Provider  to exercise or enforce any right or provision of this Agreement does not constitute a waiver of such right or provision. If any provision of this Agreement is held invalid, the remainder of this Agreement will continue in full force and effect. To the maximum extent permitted by law, any claim or cause of action arising out of or related to the use of the Service, this Agreement or the Privacy Policy must be filed within one (1) year after such claim or cause of action arose or be forever barred. The section titles in this Agreement are for convenience only and have no legal or contractual effect.

 

  1. Revision Date

 

This Agreement was last revised on August 1, 2015.

 

 

 

 

 

ANNEX I: Model cancellation form

 

-------------------------------------------------------------------------------

Model cancellation form

 

To:

IDNA B.V. 

Stadhouderskade 85
1073 AT Amsterdam
The Netherlands

 

Email: info.ie@xs2date.com

 

I/We [*] hereby give notice that I/We [*] cancel my/our [*] contract of sale of the following goods [*]/for the supply of the following service [*],

 

Ordered on [*]/ received on [*]

 

Name of consumer(s),

 

Address of consumer(s),

 

Signature of consumer(s) (only if this form is notified on paper),

 

Date

 

[*] Delete as appropriate.

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