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BUY A COUPON!

Please fill out the following form:
The price for one ticket for a dinner for 2 persons with a free registration / lottery number is € 100,-.

Payment by bank transfer:
Shortly after returning your reservation you will receive a e-mail message to the address you gave us, informing the IBAN and BIC (SWIFT) codes to be used for the bank transfer. The reserved number of tickets will be reserved for you for 14 days. As soon as the amount is credited to the escrow account, you will receive the coupon(s) and the lottery ticket(s) with the lot number by email. The ticket number/s which is/are valid immediately.

Personal details
Salutation	Mr. Mrs./Ms.
Title
First name*
Last name*
Date of birth*	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 6 7 8 9 10 11 12 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992
Country*
E-Mail*
Hint
Number of lots:	This number of tickets will be reserved for you.
Yes, I read the terms and conditions of participation and agree.*
Bank details for return remittance
Please specify your bank details for a possible return remittance (e.g. upon cancellation of the draw). In case of foreign bank transfers, also state BIC and IBAN codes.
Account holder's name
Account number
Name of the bank
Bank code number
IBAN
BIC
Security question
Due to security reasons, please enter the string of numbers and letters that you see on the picture in the adjacent field.

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* The fields marked with asterisk are mandatory details.