PERSONAL INFORMATION

Please add copy of identity card and/or passport,

Diploma of highest education and if applicable safety passport or diploma.

Surname Bergen
First name Claude
Address Avenue de Péville, 167/11
/Post code / City 4031 Grivegnée
Home telephone number 0486 62 54 06
Mobile telephone number
e-mail address Claude.bergen@gmail.com
Date of birth 09/05/1971
Place of birth Montegnée
Nationality Belge
Marital status Concubain
Name and date of birth of partner: Caroline Fejos 03/02/1976
Dependent:
YES
Children / year of birth None dependent
Dependent:
YES / NO
Passport:
 Number Lost / Need to request a new one
 Place of Issue
 Expiration date
 Date of issue
 INSZ nr (rijksregister, for Belgium
residents only)
Driver’s license 24/06/1996
Bank details: BE61 3770 2223 0417
 IBAN BBRUBEBB
 BIC
Any health issues or medication we should be Sintrom 4mg/day birth blood issue
aware of? (YES / NO, if yes explain)
In case of emergency, notify name and number: Caroline Fejos 0483 89 13 92
Safety Training / Diploma (if yes add copy
Highest education CESI
Other education of interest

I hereby declare that the information stated above is correct, I also agree that Burdock
Consultants Belgium NV will keep my personal information on record for administrative
purposes only.

Signed for approval on date, 08/02/2021

Claude Bergen