Luk Vanduffel bvba (Order form)

Personal data
Name:
Address:
Postal code/ZIP:		Residence:
State:		Country:
Telephone number:		E-mail:

Payment
Payment by VISA or MASTERCARD. For Belgium and the Netherlands it is also possible to transfer the amount to our bank account (with reference: internet order): Belgium: KBC 409-8569261-34 and the Netherlands: ABN Amro (Roosendaal) 49.74.94.787 Goods will be shipped after reception of payment.
Payment by:		Date:
Credit card type:		Signature:
Name on card:
Card number: Card security code:	_ _ _ _-_ _ _ _-_ _ _ _-_ _ _ _ _ _ _
Expiry date:	_ _ / _ _ _ _

ORDER FORM

Please print out this order form, complete and forward by post to:
Luk Vanduffel bvba - Sint-Katelijnevest 34 - BE-2000 Antwerpen - Belgium
or by fax to: in Belgium: 03-233.89.70 - from other countries: +32.3.233.89.70

I would like to order
Description Quantity Unit
price Total
price

Postage costs: Belgium: 5 EUR - Europe: 7,50 EUR - Worldwide: 10 EUR

TOTAL (in EUR)

Personal data
Name:

Address:

Postal code/ZIP:

Residence:

State:

Country:

Telephone number:

E-mail:

Payment
Payment by VISA or MASTERCARD. For Belgium and the Netherlands it is also possible to transfer the amount to our bank account (with reference: internet order):
Belgium: KBC 409-8569261-34 and the Netherlands: ABN Amro (Roosendaal) 49.74.94.787
Goods will be shipped after reception of payment.

Payment by:

Date:

Credit card type:

Signature:

Name on card:

Card number:
Card security code: _ _ _ _-_ _ _ _-_ _ _ _-_ _ _ _
_ _ _

Expiry date: _ _ / _ _ _ _

I would like to order
Description	Quantity	Unit price	Total price




Postage costs: Belgium: 5 EUR - Europe: 7,50 EUR - Worldwide: 10 EUR
TOTAL (in EUR)