I would like to order

Rules of the game in :

Price per game: 45 Euros (tax and delivery costs (Europe) included)
Delivery within not more than 10 days of receipt of payment

Pay to the following account:
IMOTEP sprl - Games conception

IBAN : (BE 29) 310 0974440 64
BIC : BBRUBEBB

1370 DONGELBERG (Belgium)

Reference: GRAILNAH - + Name + delivery address + Postcode + town

Surname:

Forename:

No. And street:

Postcode:

Town:

Country:

Email address:

....

Account used
for payment

Delivery name and address (if different from above):

If invoiced under VAT:

VAT:

(*) Prices valid until: 31/12/2006