STOP PRESSURE ULCER DAY / 16 November 2017

STOP PRESSURE ULCER DAY / 16 November 2017

ORDER FORM

KINDLY PLEASE SEND THIS FORM BY FAX TO +420 251 019 361 or by email to

PLEASE FILL IN DELIVERY ADDRESS:
Name:
Institution:
Street:
Post code: / City:
Country:
White t-shirts with STOP PU Day Logo
*t-shirt price: 6 EUR per one t-shirt
Available sizes: / Number of t-shirts per size:
S
M
L
Total amount of t-shirts
Total amount to be paid
Stickers (size: 5,5 cm or 8 cm)
*Stickers price: 3,- EUR per 10 stickers
Amount of stickers to be ordered:
Product: / Number of items: / Total amount:
T-shirts
Stickers (size 5,5 cm)
Stickers (size 8 cm)
Total amount to be paid:
For Pay Pal payment please confirm here: / YES / NO
For payment by credit card please fill in the credit card details on the following page:
Note: POSTAL FEE / SHIPMENT
Please note that postal fee is included in below prices of stickets and when ordering up to 5 t-shirts.
When ordering more, additonal shipment fee will apply.
Type of the credit card (only VISA, MC/EC and Amex)
Name of the card holder
Credit card number
CVV Code (last three digits at the back side of CC)
Expiration date
Address of the card holder/ payment confirmation receipt
TOTAL AMOUNT TO BE CHARGED*