Online form

General power of attorney and healthcare proxy

    Data sheet for the preparation of a general and health care power of attorney

    1. principal (in case of spouses please fill in principal 1 and 2)

    Power of attorney 1

    Name

    First name

    Birth name

    Birthday

    Birthplace

    Address (street, HS no., postal code city)

    Phone

    E-mail or fax

    Power of attorney 2

    Name

    First name

    Birth name

    Birthday

    Birthplace

    Address (street, HS no., postal code city)

    Telefon

    E-mail or fax

    E-mail or fax

    2. data of authorized representative (in case of mutual authorization, please enter "see authorizer ___" for name)

    Authorized representative 1

    Name

    First name

    Birth name

    Birthday

    Birthplace

    Address (street, HS no., postal code city)

    Phone

    E-mail or fax

    Relationship

    Ranking ratio of the proxy.

    Authorized representative 2

    Name

    First name

    Birth name

    Birthday

    Birthplace

    Address (street, HS no., postal code city)

    Phone

    E-mail or fax

    Relationship

    Ranking ratio of the proxy.

    Authorized representative 3

    Name

    First name

    Birth name

    Birthday

    Birthplace

    Address (street, HS no., postal code city)

    Phone

    E-mail or fax

    Relationship

    Ranking ratio of the proxy.

    Authorized representative 4

    Name

    First name

    Birth name

    Birthday

    Birthplace

    Address (street, HS no., postal code city)

    Phone

    E-mail or fax

    Relationship

    Ranking ratio of the proxy.

    By submitting the checklist, you are commissioning a chargeable draft.

    Your completed checklist will be sent in PDF format to the email address info@notar-haas-sauer.de.

    Own email address

    Comments

    (necessary field)