Application Form: (Please Print Clearly)
1. (Select Country) ____________________________
2. Name to accept mail in: _____________________
3. Code word or Number for future instructions
______________________________________
4. Name to forward mail to you: (Please note. One personal name & one Company name is acceptable in most cases. See each country as we may be able to arrange mail in unlimited names). _________________________________________________________________
5. Address: _________________________________
6. City & Postal Code: ________________________
7. Country: _________________________________
8. Special Instructions: ___________________________________________
___________________________________________
9. Payment Method:
Tick below for your preferred method of remittance: Once we receive your completed order form we'll email you the Western Union, E-gold or Bank Wire remittance details. Thank you.
[ ] Western Union [ ] Bank Wire or [ ] MoneyGram [ ] Liberty Reserve
[ ] Credit Card -
Type of Credit Card [ ] Visa [ ] MasterCard [ ] American Express [ ] Diner Club
Name as it appears on credit card :
___________________________________________
Billing address: _____________________________
___________________________________________
Credit Card Number _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
CCV 3 or 4 digit number on credit card _ _ _ _
Expiration date _ _ / _ _ _ _
Charge my credit card (don't forget postage deposit plus 5% for CC surcharge)
US$ ______________________________________
Signature: __________________________________
Please INCLUDE your e-mail address or fax number in case we need to contact you regarding this order. Thank you
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