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| Title |
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| Forename |
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(*) |
| Surname |
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(*) |
| Street |
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(*) |
| Number |
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(*) Box
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| Zipcode |
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(*) |
| City |
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(*) |
| Country |
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(*) |
| Tel. |
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| Fax |
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| E-mail |
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(*) |
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(*) Required
fields |
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| I would
like to settle with (a) : |
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Postal money order via 000-0273122-67
(De Post in Belgium) |
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IBAN:
BE93 0000 2731 2267
BIC: BPOTBEB1 |
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Transfer on account 001-4696514-44
(Fortis Bank Belgium) |
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IBAN:
BE55 0014 6965 1444
BIC: GEBABEBB
Gaston
Roelandtsplein 18, B-8310 Bruges (Assebroek)
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Visa |
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- Expiry date
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| Remarks : |
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- Please do not send cheques.
- All prices are net prices. Costs
for bank transfers or other costs are not included in
these prices. Therefore use the IBAN and BIC codes to
reduce the transfer costs.
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