Firm:

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Name

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Address

______________________________________

City / Zip / Country

______________________________________

Tel:

______________________________________

Fax:

______________________________________

E-Mail:

______________________________________

I have shipped to you following:

Please describe:

___________________________________________

Payment:

Payment Info

Payee:

________________________________

Bank name:

________________________________

Account number:

________________________________

SWIFT/BIC number::

________________________________

Herewith I explain in oath Instead of that the product described on top is my unlimited property, comes from no punishable action and is neither pledged nor is conveyed and I am fully able of business. .

Place and Date:

_______________________

Signature:

_____________________