Historical Diving Society - Order Form
PLEASE COMPLETE IN BLOCK CAPITALS

 

YOUR ADDRESS

DELIVERY ADDRESS if different

TITLE

 

 

FIRST NAME

 

 

LAST NAME

 

 

ADDRESS

 

 

 

 

 

POST CODE

 

 

COUNTRY

 

 

TELEPHONE NUMBER please supply a daytime telephone number

ITEM

COLOUR

SIZE

QUANTITY

COST

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
         

POST & PACKING

  

GRAND TOTAL

 

METHOD OF PAYMENT please tick
CHEQUE
 
POSTAL ORDER
 
ACCESS
 
MASTERCARD
 
VISA
  
AMERICAN EXPRESS
 
CARD NUMBER
                               
SECURITY CODE
last 3 digits of code on signature strip
      
EXPIRY DATE
        

NAME OF CARD HOLDER:

PLEASE POST COMPLETED FORM TO: Una Smillie, 29 Pingle Croft, Woodend, Chorley, Lancs, PR6 7UL, or FAX to 01772 493813