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 (150€/Volume)
Postage costs	25€
TOTAL	€

By bank transfer to:
Bank name : DEXIA
Account name : LAP SURGERY
Account number : 068-2315238-69
Codes: IBAN : BE71 0682 3152 3869 - BIC/SWIFT : GKCCBEBB
* Please indicate as communication : subject + full name + country
** For participants outside the Eurozone : total amount + 2,75 % for bank and administrative charges.

OR

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