ORDER FORM

"The WebCashpoint Series"

 

Please complete the form below and either post it back to us at our address (shown at the bottom of this page) or FAX it to us at 01608 645363

Please Fill in your Information Below

Please charge my credit/debit card Visa / MasterCard / Switch / Solo / Delta / JCB the sum of £71.95 (i.e. £67.00 + £4.95 p&p)

Cardholder's Name (as it appears on the card):

_______________________________

Signature:

_______________________________

Expiry Date:

3 or 4 digit Security Code (on reverse of card above signature strip):

Valid From:

Card Issuer (eg. "Barclays" or "MBNA"): _____________________

Switch/Solo Issue No.:

OR

Please find enclosed my cheque/postal orders for £71.95 (i.e. £67.00 + £4.95 p&p) made payable to La Pa Limited.

 

Delivery Details

Date:

Mr/Ms/Mrs/Miss/Other:_______________________________

Name:_______________________________

Address:_______________________________

____________________________________

____________________________________

Postcode:___________________

Tel:________________________

Fax:________________________

e-mail:________________________________

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