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| Purchasers Name: | |
| Address: | |
| Address Con't: | |
| City: | |
| State: | Zip Code: |
| Country: | |
| Phone Number: | |
| Fax Number: | |
| E-mail: | |
| Cardholders Name: (Must be that same as the purchaser's name) |
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| Card Number: | |
| Expiry Date: | |
| Cardholder's Signature: |
| Series/Model | Part No: | Description | Quantity | Price |
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| Please print this page, fill in your payment and delivery details and either Fax to: 0064 9 636 4953 | ||||
| OR | ||||
| Post to 41A Heretaunga Ave, Onehunga, Auckland, New Zealand | ||||
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TERMS AND CONDITIONS OF AGREEMENT - All purchases are payable in full by Credit Card, Bank draft/Cheque (overseas payments). |
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| Credit Card OR Bank Draft/Cheque |
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