You can also use this form for mail orders... Mail your check
or money order to:
Alain Van Kerckhoven Editeur, 110 avenue Broustin, BE-1083 Brussels, Belgium
Make Checks Payable to Alain Van Kerckhoven Editeur
Print this form and fax it to us, or
cut and paste it into your text-processor and fax-modem it to us.
Your purchase is risk-free!
Name: _________________________________________________
Shipping Address: _________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Credit Card Number: _________ _________ _________ _________
Expiration Date: ________________
Circle One: VISA MASTERCARD
Name on Card: _________________________________________________
Phone Number: _________________________________________________
E-Mail Address: _________________________________________________
The scores and/or CD you'd like:
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Shipping Amount: _________________________________________________
Total Order Amount: EUR _________________
How Do You Want It Shipped to You? (Circle One)
European Union :
x EUR 2.50 for up to 3 scores and/or CDs
x EUR 3.50 for more than 3 scores and/or CDs
Outside European Union :
x EUR 4.00 for up to 3 scores and/or CDs NON-PRIOR
x EUR 7.00 for up to 3 scores and/or CDs **PRIOR**
x EUR 8.00 for more than 3 scores and/or CDs NON-PRIOR
x EUR 13.00 for more than 3 scores and/or CDs **PRIOR**
Fax to +322-420-0505