|
Name: |
_______________________________ |
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|
Organisation: |
_______________________________ |
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|
Email: |
_______________________________ |
|||
|
Street & Nbr: |
_______________________________ |
|||
|
City: |
_________________ |
State: |
_________________ |
ZIP: _________________ |
|
Phone: |
_________________ |
Fax: |
_________________ |
|
|
Credit card information |
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|
Card type: |
[_] VISA [_] Eurocard/Mastercard |
|||
|
Card number: |
____________________ eg: 1234-5678-9012-0000 |
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Expiration: |
________ eg: 06/01 |
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|
Cardholder name: |
_______________________________ |
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|
Product |
Qty |
Price |
|---|---|---|
|
Video Saint Lucia |
___ |
16.50 US$ or 15 EUR (599 BEF or ±10 GBP) |
|
Language video |
Format video |
|
English |
[_] VHS PAL [_] VHS NTSC |
|
German |
[_] VHS PAL |
|
French |
[_] VHS PAL [_] VHS SECAM |
|
Dutch |
[_] VHS PAL |