Order Form for France

(Please print and fill out the form below)

Please Add Shipping & Handling: 8.50 Euros per shipment, to be added to your check, in Euros, paid for either through a French Bank or through a French Postal order, to the order of Jacques SURBECK.

IN ORDER TO AVOID ANY SHIPPING MISTAKES, KINDLY WRITE IN CAPITAL LETTERS AND LEGIBLY (information in bold is required, the other is not). All information provided here will remain confidential and will not be used for advertising purposes.

Last Name: ______________________________________________________________

First Name: _____________________________________________________________

Address: _______________________________________________________________

ZIP: _______________ City: ________________________________________

Telephone______________________________ Fax: ___________________________

E-mail: _________________________________________________________________

Location and date: ____________________________________________________________

Signature: ___________________________________________________________

Purchase recommended by: _____________________________________________________