European Community

(Please print and fill out the form below)
Important Note: This form is valid for all European Union countries
except France.
For orders to France, click here.

+ Shipping & Handling: Euros 10.00 per shipment.
VAT costs, as per each country's percentage, will be paid to the mailman on receipt.

Please send your check, in Euros, either through a bank or through a postal order, made payable to Jacques SURBECK.

IN ORDER TO AVOID ANY SHIPPING MISTAKES, KINDLY WRITE IN CAPITAL LETTERS AND LEGIBLY (information in bold is required, the others are 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: _____________________________________________________