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Salutation

Salutation

Please select ... Mr. Ms. Mrs.

Company Name

First Name *

This field is mandatory and must be filled in.

Last Name *

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Contact data

Email *

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Data

Blocking Reason *

Please select ... Card Lost Licence plate / vehicle change Card defect Card no longer required Card stolen Other

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Blocking date (immediately/at) *

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Customer number LOGPAY

Text on Card

Card number

Disclaimer

I have read the privacy policy and hereby agree to it. *

* Mandatory fields (must be completed)