Manual order processing form:
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Make a printout of this form, fill out all fields in BLOCK PRINT and return to: ISHS, PO Box 500, 3001 Leuven 1, Belgium or FAX +32 16229450 or
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Cards
Accepted |
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[] Prof. [] Dr. [] Mr. [] Ms. [] Male [] Female Last Name ________________________________________________ First Name _______________________________________________ Affiliation ______________________________________________ Address __________________________________________________ City _________________________________ Zipcode ___________ State/Province _______________________Country_____________ Phone _______________________ Fax ________________________ E-Mail ___________________________________________________ CARDNUMBER _______________________________________________ Valid Thru ____/____ CARDHOLDERS NAME _________________________________________ Authorised Signature _____________________________________ |