CAVIP Fax Order form

FAX Nbr: + 32 9 330 4984

Name:

_______________________________

Organisation:

_______________________________

Email:

_______________________________

Street & Nbr:

_______________________________

City:

_________________

State:

_________________

ZIP: _________________

Phone:

_________________

Fax:

_________________

Credit card information

Card type:

[_] VISA [_] Eurocard/Mastercard

Card number:

____________________ eg: 1234-5678-9012-0000

Expiration:

________ eg: 06/01

Cardholder name:

_______________________________

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