Please (1) Print this form. (2) Use a pen to fill the form. (3) Fax the form. Thank you.
CIAX.COM
CIAX.COM, 5 LONGHEY RD, MANCHESTER, M22 8UA, UNITED KINGDOM
Tel: +44 161 902 0980 Fax: +44 161 945 8169 Email: helpCIAX.com

FAX: +44 161 945 8169

 
ORDER NUMBER: DATE:

ADDRESS: Must be the billing address of the credit card

CONTACT: COMPANY:
ADDRESS:
CITY: POST CODE / ZIP:
TEL: FAX:
EMAIL: <<< IMPORTANT: Email address for delivery of software
ORDER CODE PRICE QUANTITY SUB-TOTAL
   
= E
    x
= E
    x
= E

VAT / BTW / IVA / TVA / FPA / MOMS / MWST:
(If you enter a * VAT NUMBER then add 0%, otherwise you must add 17.5%)

+ E

TOTAL:

EUR
* VAT NUMBER / N° TVA / BTW / NIF / UID-NR / USt.-IdNr / MOMS-Nr / SE-nr / ALV-NRO / A M / PIVA / NIPC:
                             
* BE, FR - Numéro d'identification à la TVA intercommunautaire / Numéro d'identification à la taxe sur la valeur ajoutée / BTW-identificatienummer. ES - Número de identificación a efectos del Impuesto sobre el Valor Añadido. AT, DE - Umsatzsteuer-Identifikationsnummer (USt.-IdNr.). SE - Registreringsnummer for Mervardesskatt. DK - Momsregistreringsbzmmer. FI - Arvonlisäveronumero. EL - Anthmos Forologikou Mitroou FPA. IT - Numero di registrazione IVA. PT - Numero de identificação para efeitos do imposto sobre o valor acrescentado.
CREDIT CARD NUMBER:  [  ] VISA  [  ] MASTERCARD  [  ] ACCESS  [  ] SWITCH  [  ] AMERICAN EXPRESS
                                                 
SECURITY: Last 3 digits (or 4 digits) printed on back of your card, printed on the Authorised Signature strip usually.
                 

VALID FROM DATE: (Example: 04 / 2004)

EXPIRY DATE: (Example: 06 / 2007)

    /        
    /        

SWITCH ISSUE NUMBER: (For SWITCH cards only)

           

CARD HOLDER'S NAME:

CARD HOLDER'S SIGNATURE: