| Email:
_________________________ |
| Address:
______________________ |
| City:
__________________________ |
| State: __________ |
| Country:
____________ |
| Post Code: _________ |
| Phone: (___) ____-
______ |
( ) I am
enclosing a cheque or money order.
If you are paying by
cheque or money
order you must mail it in to the address above.
I will send my Cheque (Inside Australia only) by
snail mail.
Please make Cheque and Money Order out to: D. A Van Zanten |
For
overseas orders please send only Bank Draft made out in
Australian Dollars and Drawn on an Australian Bank.
|
| ( ) I want to
charge this purchase to my Credit Card Amount: Please workout
following amount |
| Credit Card (Please tick one box): |
|
|
|