Title
                    Surname
             Name
       Street address
    ZIP, City
  Country
E-Mail
Amount   (each € 68,- incl. VAT)
  Type
     On advance payment (€ 5,95 shipment)            W-W in gold
        Payment on delivery (€ 8,50 plus € 5,95 shipment)
           Total amount € 73.95  GTC accepted