This form is used to request a photo shoot in the orange retro bathroom. In the section info photo shoot you find general information about this shoot. Please carefully fill in below fields; mandatory fields are marked with a star (*). Data are needed to formulate the agreement by letter. When finished, please click the "submit my data" button to send the form. Thank you.

Please note: due to the shoot location is in the city of Breda (Netherlands), this request form is meant for residents of The Netherlands and Belgium only.

first name and family name *
first letters or initials
street and number *
postal zip and city *
country *

mobile phone number*
private line (at home)
email *

city and country of birth *
date of birth *

comes along with somebody to the shoot

your own website


record my personal data *
As mentioned in the privacy statement, this site respects your privacy: your personal data will not be shared with anyone. I agree my personal data will be part of the administration.

record my IP-address *
Each computer that is connected with the internet has its own, unique number: the IP-address. That number can be used to find out from which computer data had been sent. The computer you are currently working with, has IP-address . This IP-address will be recorded with your registration.
I agree my IP-address will be recorded.

click the button on the right

registration disclaimer
A registration can be rejected without reported reason.

Thank you for your interest
to pose for this site.