ORDER FORM
| this form, fill in and sent it back with your payment to : |
Musée des Manufactures de Dentelles, "Modèles anciens",
14 avenue de la gare,
43130 Retournac, FRANCE.
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Name, First name : |
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Address : |
___________________________________________ |
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___________________________________________ |
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Order the set(s) n° : |
___________________________________________ |
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for a total
amount of |
___________________________________________ |
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r I wish to give these(s) Set(s) to (Name, first name, address) |
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_____________________________________________________ |
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We undertake to join free of charge to this gift a card mentioning your name. |
| I pay by : | |
| r Bank Card | |
| r Visa r Eurocard r Mastercard r American Express | |
Card n° : __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ |
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Expiry date : ________________________________ |
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Holder name and first name : _______________________ |
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| r Cheque (in FF ou € for France) to " Amis du Musée de Retournac" | |
| r Western Union | |
| r International postal order to postal account n°3775 27 M CLERMONT | |
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r
International interbank credit
transfert in FF to postal account n°FR 31 20041 01003 0377527M024 46 31 |