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fax and payment by bank transfer
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WILHELMUS VAN EWIJK
- Fax.
+65 622 701 87
10 Anson Road - # 15-14
International Plaza – Singapore 079903 E-mail :
biologicsinternational@hotmail.com
Void where prohibited
by law.
www.anticancerplacentatherapy.com
ORDER FORM-2009/2010
-VG1000 SUPPOSITORIES
ALLOW 5 WORKING DAYS FOR
SHIPPING
Name
______________________________________
Street
/Address ______________________________________
City/State/Zip ______________________________________
Country
______________________________________
Phone
______________________________________
Fax
Number
______________________________________
E-mail ______________________________________
Physician Clinic
______________________________________
Food
Supplement Price Per Item Quantity Required Total Price
VG-1000 Suppositories
Carton of 10 €319.-- ______ € ________
Carton of 30 €869.-- ______ € ________
Carton of 60 €1.697.-- ______ € ________
Carton of 80 €2.054.-- ______ € ________
Handling and shipment
by registered priority
mail € 30.-
Total
amount €
==========
Payment by Bank only:
Beneficiary
Bank : Citibank, N.A.
Singapore, Attn.: IPB
Corresponding
Bank : CR Citibank London
For account of Citibank Singapore
No. 5516498 / Attn: IPB
Swift code/BIC
: CITISGSG
Beneficiary Account
no.
: 6 429773
006
Beneficiary
Name : Wilhelmus van Ewijk
Signature :
___________________________________
Please fax or
scan and
@mail signed order and copy of your payment by Bank to
fax number: +65 622 701 87 or
biologicsinternational@hotmail.com
