Registratie GMP en Spuitlicentie

[av_contact email=’arie@agrofarmshop.nl’ title=’Registratie- formulier’ button=’Verzenden’ on_send=” sent=’Uw bericht is verstuurd!’ link=’manually,http://’ subject=” autorespond=’Bedankt voor het invullen van het (registratie)formulier!

Uw gegevens worden vertrouwelijk worden behandeld.

Met vriendelijke groet,
Rik van der Kooij

Agro Farm Shop’ captcha=” form_align=” color=” admin_preview_bg=”]
[av_contact_field label=’Naam’ type=’text’ check=’is_empty’ options=” multi_select=” av_contact_preselect=” width=”][/av_contact_field]
[av_contact_field label=’Straat ‘ type=’text’ options=” check=’is_empty’ width=’element_three_fourth’ multi_select=” av_contact_preselect=”][/av_contact_field]
[av_contact_field label=’Huisnummer’ type=’text’ options=” check=’is_empty’ width=’element_fourth’ multi_select=” av_contact_preselect=”][/av_contact_field]
[av_contact_field label=’Postcode’ type=’text’ options=” check=’is_empty’ width=’element_third’ multi_select=” av_contact_preselect=”][/av_contact_field]
[av_contact_field label=’Plaats’ type=’text’ options=” check=’is_empty’ width=’element_two_third’ multi_select=” av_contact_preselect=”][/av_contact_field]
[av_contact_field label=’Telefoonnummer’ type=’text’ options=” check=’is_phone’ width=’element_half’ multi_select=” av_contact_preselect=”][/av_contact_field]
[av_contact_field label=’Mobiel telefoonnummer’ type=’text’ options=” check=” width=’element_half’ multi_select=” av_contact_preselect=”][/av_contact_field]
[av_contact_field label=’E-Mail’ type=’text’ options=” check=” width=” multi_select=” av_contact_preselect=”][/av_contact_field]
[av_contact_field label=’UBN- nummer’ type=’text’ options=” check=” width=’element_half’ multi_select=” av_contact_preselect=”][/av_contact_field]
[av_contact_field label=’UBN- nummer (2)’ type=’text’ options=” check=” width=’element_half’ multi_select=” av_contact_preselect=”][/av_contact_field]
[av_contact_field label=’Spuitlicentie’ type=’select’ options=’Geen Spuitlicentie,Uitsluitend KBA,Spuitlicentie 1,Spuitlicentie 1 + KBA,Spuitlicentie 2,Spuitlicentie 2+KBA’ check=” width=’element_third’ multi_select=” av_contact_preselect=”][/av_contact_field]
[av_contact_field label=’Pasnummer Spuitlicentie’ type=’text’ options=” check=” width=’element_third’ multi_select=” av_contact_preselect=”][/av_contact_field]
[av_contact_field label=’Geldig tot’ type=’datepicker’ options=” check=” width=’element_third’ multi_select=” av_contact_preselect=”][/av_contact_field]
[av_contact_field label=’Pasnummer Spuitlicentie 4 ‘ type=’text’ options=’ja,nee’ check=” width=’element_half’ multi_select=” av_contact_preselect=”][/av_contact_field]
[av_contact_field label=’Geldig tot’ type=’datepicker’ options=” check=” width=’element_half’ multi_select=” av_contact_preselect=”][/av_contact_field]
[av_contact_field label=’Wilt u onze factuur per mail ontvangen? ‘ type=’select’ options=’ja,nee’ check=’is_empty’ width=” multi_select=” av_contact_preselect=”][/av_contact_field]
[av_contact_field label=’Indien ja, naar welk E-mail adres? ‘ type=’text’ options=” check=” width=” multi_select=” av_contact_preselect=”][/av_contact_field]
[av_contact_field label=’Opmerkingen’ type=’textarea’ options=” check=” width=” multi_select=” av_contact_preselect=”][/av_contact_field]
[av_contact_field label=’Licentie nummer 1′ type=’text’ options=” check=” width=” multi_select=” av_contact_preselect=”][/av_contact_field]
[/av_contact]