Contact

Diako easyfit
Arkansasdreef 30d
3565 AR Utrecht

T: 030-82 000 30
F: 030-82 000 39
E: info@diako-easyfit.nl

Rabobank 14 71 35 443
Company Reg. No.:30247466

IBAN: NL88RABO0147135443
BIC: RABONL2UDO

Name + surname:
Street + house number:
Place of residence + postal code:
Country:
Telephone number:
E-Mail:
Repeat e-mailaddress:
Gender:
Date of birth:
How many kilos now:
Wat is the desired weight:
Binnen hoeveel tijd op streefgewicht:
How did you find Diako easyfit:
Do you wish to receive the newsletter:		Yes No