FAX FORM

TO ACADEMIA PRESS

Fax + 32 9 233 14 09

BILLING ADRESS

Name:

Fax:........................................ : E-mail:..................................................................

Institution:

Street:

City/State:..................................................... ZIP:.............. Country:...............................

ORDER FORM

Number of books ..... X 20 EUR = ........ EUR

Shipping cost ..... X ... EUR = ........ EUR

(Shipping costs per unit :

Belgium 4 EUR; Europe 9 EUR; Other continents 14 EUR)

__________________________________________________________

TOTAL ........ EUR

VISA CARD DATA

VISA Nr: Expiry Date:

Name (as given on card):

Date:.................. Signature:....................................................

SHIPPING ADRESS (only if different from billing adress)

Name:

Institution:

Street:

City/State:...................................................... ZIP:............... Country:...................................................