ID		Cust Ref
Title	Forename	Inits	Surname
Job Title
Dept.
Comp
Addr 1
Addr 2
Addr 3
Town		County
P’code		Country	Choose country… UK USA Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antartica Antigua and Barbuda Argentina Armenia Aruba Ascension Island Australia Austria Azerbaijan Azores Bahamas Bahrain Balearic Islands Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia-Herzegovina Botswana Bouvet Island Brazil British Indian Ocean British Virgin Islands Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Canary Islands Cape Verde Cayman Islands Central African Rep. Chad Chile China Christmas Island Cocos Island Colombia Comoros Congo Cook Islands Corsica Costa Rica Cote d’Ivoire Croatia Cuba Cyprus Czech Republic Dem. Rep. of the Congo Democratic Peoples Rep. of Korea Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Federated States of Micronesia Fiji Finland France French Guiana French Polynesia French Southern and Antarctic Territories French West Indies Gabon Gambia Gaza and KhanYunis Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey, C.I. Guinea Guinea-Bissau Guyana Haiti Heard and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey, C.I. Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Madeira Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Moldavia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherland Antilles Netherlands Netherlands Antilles Neutral Zone (Saudi/Iraq) New Caledonia New Zealand New Zealand Island Territories Nicaragua Niger Nigeria Niue Niue Island Norfolk Island Northern Mariana Islands Norway Oman Other Pakistan Palau Palestine Panama Panama Canal Zone Papua New Guinea Paraguay Peru Philippines Pitcairn Island Poland Portugal Puerto Rico Qatar Republic of Congo Republic of Korea Reunion Romania Russia Rwanda Sabah San Marino Sao Tome and Principe Sarawak Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia South Sandwich Islands Spain Spanish North African Territories Spitzbergen Sri Lanka St Helena St Kitts and Nevis St Lucia St Pierre and Miquelon St Vincent and Grenadines Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Tibet Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu UAE Uganda Ukraine Uruguay US Virgin Islands Uzbekistan Vanuatu Vatican City State Venezuela Vietnam Wake Island Wallis and Futuna Islands Western Sahara Western Samoa Yemen Zambia Zimbabwe
Telephone		Mobile
Fax		Website
Email
Badge Id.		Reg Code
Badge Type
Invoice no
Voucher		Old ID

 
 

ABC Addressee Type:	– select ABC Addressee Type – 40 -Individually requested in writing 41 – Individually requested by telephone 48 – Individually requested by internet 42 – Company requested in writing 43 – Company requested by telephone 49 – Company requested by internet 44 – Non-requested by name – sourced 46 – Non-requested by job title/function – sourced 51 – Non-controlled free circulation – By name 52 – Non-controlled free circulation – Not by name 99 – Other addressee (not claimed on ABC Return)
Override no of copies
Registration Date:
Card is Signed Card is Dated
Source:
Notes:
Personal identity question:	Type question or select Please choose from the list below Please choose from the list below Type answer