BESTELFORMULIER VOOR BETALING (IN EURO) VAN PUBLICATIES PER CREDIT CARD

ORDER FORM FOR PAYMENT (IN EURO) OF PUBLICATIONS  BY CREDIT CARD

 

Dit formulier na invulling en ondertekening sturen naar Dhr. C. Leeda, Van Neslaan 7, 3742 MN Baarn, Nederland/
Please complete and sign this form and return to Dhr. C. Leeda, Van Neslaan 7, 3742 MN Baarn, The Netherlands

 

Naam/Name:                        ……………………………………………………………………………………………………...

 

Adres/Address:                   ……………………………………………………………………………………………………...

 

Woonplaats/City:               ……………………………………………………………………………………………………...

 

Postcode/Zip code:            ……………………………………………………………………………………………………...

 

State/Province:                   ……………………………………………………………………………………………………...

 

Country:                               ……………………………………………………………………………………………………...

 

Telefoon/Phone:                 ……………………………………           Fax/Fax                 ……………………………………

 

E-mail/E-mail:                      ……………………………………………………………………………………………………...

 

Publicatie nr./Publication no.          Titel/Title                                                                                            Prijs/Price

 

....................                                           ....................................................................................................      €    ........................

 

....................                                           ....................................................................................................       €    ........................

 

....................                                           ....................................................................................................       €    ........................

 

Buiten Europa € 5,- verzendkosten toevoegen/Outside Europe please add € 5.00 for postage           €    ........................

                                                                                                                                                                                       _______________

 

Totaal/Total                                                                                                                                                        €    ........................

 

Ik machtig de NKvJG om de volgende rekening te belasten voor het verschuldigde bedrag/I authorize the NSfJG to charge the total for this order to the following account

 

c Mastercard/Eurocard              c Visa             c American Express

 

Card no                 cccc  cccc  cccc cccc

 

Voor Master/Eurocard en Visa de laatste drie cijfers op de handtekeningstrip op de achterkant van de kaart/For Master/Eurocard and Visa the last three digits on the signature strip at the back of the card         ccc

 

Geldig tot/Valid until         cc / cc

 

Naam zoals vermeld op de kaart/Name as printed on card ………………………………………………………..

 

 Datum/Date: ……………...………….               Handtekening/Signature: ……………………………………………