Alicia Applegate,

an individual, born on 1978-03-25 at Boston, Massachusetts, United States of America,
a citizen of United States,
whose profession is doctor,
residing at 55 Broadway, Cambridge, MA 02142, United States of America,
herein referred to as "{Handle}",

Alicia Applegate,

Née le 1978-03-25 à Boston, Massachusetts, United States of America,
de nationalité Etats Unis,
Exerçant la profession de médecin,
Demeurant 55 Broadway, 02142 Cambridge , United States of America,
ci-après dénommée la « {Handle} »,

Alicia Applegate

urodzonym dnia 1978-03-25 w Boston, Massachusetts, United States of America,
posiadającym obywatelstwo Stany Zjednoczone Ameryki,
z wykształcenia {Work.profession},
zamieszkałym pod adresem 55 Broadway, Cambridge, MA 02142, United States of America
zwanym dalej «{Handle}»,

Alicia Applegate

("{Handle}")

{xSignature}

Date: {Sign.YMD}
Signed at: Cambridge, Massachusetts, United States of America

Alicia Applegate

( « {Handle} » ),

{xSignature}

le : {Sign.YMD}
à : Cambridge, Massachusetts, United States of America

Alicia Applegate

("{Handle}")

{xSignature}

Dnia: {Sign.YMD}
Podpisana w: Cambridge, Massachusetts, United States of America