CLICK HERE; PRINT THIS FORM AND FAX TO NUMBER: ++31 (313) 450 804
(where ++ denotes the international phone access code and 31 the country # of The Netherlands)
ADDRESS, STREET:........................................................................................................
CITY:...............................................................................................................................
STATE (+ ZIP):..................................................................................................................
COUNTRY:.......................................................................................................................
TELEPHONE NUMBER:.....++..............(....................)........................................................
FAX NUMBER:..................++..............(....................).........................................................
E-MAIL ADDRES:...............................................................................................................
CURRENT DATE (MONTH/DAY/YEAR).................................................................................
............ORCHID CD-ROM(S) English/Espaņol/Deutsch/Nederlands (PLEASE CIRCLE LANGUAGE) @ US$ 49.- (+US$ 5.50 S+H) EACH; TOTAL US$................................
(Free Orchid Databases CD ROM (English Langauage) is included)
............FUCHSIA CD-ROM(S) English/Nederlands (PLEASE CIRCLE LANGUAGE) @ US$ 34.- (+US$ 5.50 S+H) EACH; TOTAL US$................................
METHOD OF PAYMENT (PLEASE CIRCLE) : VISA / MASTERCARD / AMEX / EUROCARD
CARD NUMBER:.................................................................................................................................
EXPIRATION DATE:............................................................................................................................
CVV2/CVC2 CODE:............................................... (The CVV2/CVC2 code is the three or four-digit security code that is printed on credit cards. The value appears in reverse italic at the top of the signature panel on the back of the credit card, or just above the end of the credit card number on the front of the card)
NAME AS PRESENT ON CARD:...............................................................................................................
SIGNATURE OF CARD HOLDER:.............................................................................................................
OR MAIL TO:
MöhltiMedia Publishing
ED. V. BEINUMLAAN 129
6952 CL DIEREN
THE NETHERLANDS
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