Mr. / M. / Herr      Mrs / Mme / Frau      Miss / Mlle / Frl.
 
   First name / Prénom / Vorname

   Last name / Nom / Name           

   Adresse / Address                     

   Town / Ville / Ort                          

   ZIP    State (US only)

   Country / Pays / Land 

   E-mail address           

  I order / Je commande / Ich bestelle

   Duopack A-Q-Pressor (2 p.)       US$ 26.00 (€ 16.00)
   Familypack A-Q-Pressor ( 4 p.)  US$ 36.00 (€ 24.00)
        Postage included / Port compris / Porto inbegriffen

    Payment in advance by bank transfer to account 320357-42-1 at CREDIT SUISSE, Box 2493, CH-1002 Lausanne (Switzerland)
    SWIFT CRESCHZZ10A. IBAN: CH50 0483 5032 0357 4100 0, bank charges at buyer's expense.
    Please do not send a cheque, it will be destroyed.