DVD ORDER FORM

COORDINATES

Please specify where the DVD 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
LAPAROSCOPIC COLORECTAL SURGERY - Quantity
LAPAROSCOPIC HERNIA REPAIR - Quantity
Price (290€/Volume)
Postage costs	15€
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: Dvds - 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)