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First Name:
Last Name:
Street:
Postal Code:
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State:
Country:
E-Mail:
shipping :
air/mail
  sea/land
insurance :

(only necessary

for shipping one bottle)
yes
  no

Order: (quantity) - (the item number) - (item)

e.g.: 2 - hm023200 - Glendronach
(please copy item with control+C in the list
and fill in here with control+V)

 

Please send this order with the auction bottles,
if I am successful in bidding.
   
I pay by creditcard

  Payment by creditcard:

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Creditcard: Eurocard / Mastercard 
  VISA
  American Express
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Cardnumber:| Expiration Date (e.g. 01/04):  

     

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