Consultation request form

First Name:		Family Name:
Email:		Phone:
Address:		City:
Zip/Postal:		Country:

Please state your Birth date, time and place:

Sex:	please select female male	Birthplace / Country:
Year:	year 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1938 1937 1936 1935 1934 1933 1932 1931 1930	Month:	Dezember November October September August July June May April March February January month	Day:	day 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1	Hour:	hour 23 22 21 20 19 18 17 16 15 14 13 12 11 10 09 08 07 06 05 04 03 02 01 00	Minute:	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 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 min.

What type of consultation do you request?
On Site
Off Site (via email)

Type of consultation request: please select one Residential Property Commercial Property Commercial and Residential Property Property Design Floor Plan and Site COMPARISON Floor Plan and Site EVALUATION other Annual follow up

Size of property in m2	please select up to 150 up to 300 up to 450 over 450	or Size of property in ft2	please select up to 1600 up to 3200 up to 4800 over 4800
Building year of the property:	2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1938 1937 1936 1935 1934 1933 1932 1931 1930
Year you moved in:	2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1938 1937 1936 1935 1934 1933 1932 1931 1930

Please indicate the dates of major renovations and the work carried out:

Please give a short indication where you would like to have help:

How would you like to pay? please select one Cash, at first visit PayPal other

Payable to:
Juergen Wessel
780/40 Charoenkrung Rd.
Bangkholaem
Bangkok 10120
THAILAND
Phone / Fax: +66 26890439

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