Ostermann pipes Vienna, order fax form

ORDER FAX !!! date……

To Josef Ostermann Pipes

Am Hof 5

A-1010 Wien

Austria

Europe

Tel: +43 1 5334242

Fax: +43 1 5332542

My information:

· Full Name: ....................

· Credit Card Type: ....................

· Credit Card Number: ....................

· Expiry Date: ....................

· Address on Credit Card (if so): ....................
· Security Code: (3 digits on the backside of the card) .....................

· Signature (as on Credit Card): ....................

· Shipping Address:....................

· E-mail Address for confirmation:....................

I would like to order the following items:

1. Item #1 (order code) ----------------------------------------------------------------

2. Item #2 (order code) ----------------------------------------------------------------

3. Item #3 (order code) ----------------------------------------------------------------

4. Item #4 (order code) ----------------------------------------------------------------

5. Item #5 (order code) ----------------------------------------------------------------

6. Item #6 (order code) ----------------------------------------------------------------

7. Item #7 (order code) ----------------------------------------------------------------

8. Item #8 (order code) ----------------------------------------------------------------

9. Item #9 (order code) ----------------------------------------------------------------

10. Item #10 (order code) -------------------------------------------------------------

Order comments:

date: signature: