ATLAS ORDER FORM

COORDINATES

Please specify where the atlas should be sent:
Title	Lastname	Firstname
Hospital
Business address:
Address
City	ZipCode	Country
Tel	Fax	Email
Private address:
Address
City	ZipCode	Country
Tel	Fax	Email

PAYMENT
Quantity
Price (290€/Volume)
Postage costs	25€
TOTAL	€

By bank transfer
Bank transfer to the account DEXIA 068-2315238-69
Codes: IBAN: BE71 0682 3152 3869 - BIC: GKCCBEBB
(** please indicate as communication: Atlas - Your Full Name - Country)
Payment by cheque will not be accepted

OR

By Credit Card : Diners Eurocard VISA AMEX
Number:
Expiration date : Code Verify (3 last digit of card number):
Please charge my credit card (+2,75% for bank and administrative charges)