CD-rom order form

This page allows you to order our publications in a secure and easy way. If you require assistance or have any queries, don't hesitate to let us know: ludwig@ombregt.be -

Fill in this order form, print it, sign it and
fax it to :

+32(0)51687712

 or send it to:
Ombregt vof
Kanegemstraat 170
8700 Tielt / Belgium 		you can also make an order by phone:
+32/51689995
or by E-mail:
lombregt@compuserve.com

Products, together with the invoice will be shipped by Ombregt vof within two weeks upon receipt of payment.

Yes, I would like to order the following CD-roms at the price of 95 euro
Product Information    
Select product    
Postage and Packing    

The prices are inclusive VAT. All orders are billed for applicable tax rates. Total to pay:    
 
Customer Information (Bill To)    
First Name    
 Last Name    
Street Address    
City    
State    
Country    
Zip Code    
 E-mail adress:    
Payment by Credit Card    
Please note that if you wish to pay by credit card, you must print out this form, sign and date it and fax it/send it by mail to Ombregt vof.
All credit card orders are accepted via Europabank , Burgstraat 170, B-9000 Gent.
I hereby authorize Ombregt vof to bill my credit card for the summ of: :
 
VISA
MasterCard
Card Number (including last three digits)
Expiration
 
Payment by Cheque    

Please note that if you wish to pay by cheque, you must print out this form and send it with your cheque by mail.
Yes; I would like to pay by cheque and I attach a cheque ( made payable to Ombregt vof) in the summ of:
Date and signature: (The date and your signature are essential when paying by credit card)

 

 
 
User Information    
All CD-roms are personalized ; they have a User name and a serial number
Please fill in the two fields you want to have on your personalized copy:
Name    
 City :