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["                                                     BOLDKLUBBEN 1909"]
[]
["Baneanlæg:  Gillestedvej 12, 5240 Odense NØ"]
["Tlf. 66 10 29 09"]
[]
[]
[]
[null,null,"         UDMELDELSESBLANKET"]
[]
[]
["Medlemsnummer:",null,null,null,"Spillergruppe:"]
[]
[]
["Navn:",{"$nulls":4},"Fødselsdag:"]
[]
[]
["Adresse:"]
[]
["Postnr.",null,null,null,"By:"]
[]
["Bemærkninger: (angiv altid  årsag til udmeldelse)"]
{"$rows_empty":7}
["Dato:",null,null,"Underskrirft: _________________________________________"]
[]
["                                              Forbeholdt B1909:"]
["Spillercertifikat udleveret/sendt                Ja____                   Nej:____"]
["Hvis nej - angiv årsag.  Evt. Restance til klubben Kr. _____"]
[]
[]
[]
[]
[]
[]
["Indberettet til FBU           Dato:",{"$nulls":5},"Navn:_______________"]