Order Form
Please fax or send your order to:
Sirius GmbH, P.O. Box 5205, 65042 Wiesbaden, Germany, Fax: ++49 - 611 - 599806
| Item | Price in Euro per item | Quantity | Total |
| __________ | __________ | ||
| __________ | __________ | ||
| __________ | |||
| __________ | __________ | ||
| Special Offer Book and Phonecard Package | |||
| ## Special Offer Comic and Disney Package ## | 39 | __________ | __________ |
| ## Special Offer Ayrton Senna Package ## | 49 | __________ | __________ |
| ## Special Offer Coca-Cola Package ## | 99 | __________ | __________ |
| ## Special Offer Japan Package ## | 69 | __________ | __________ |
| __________ | __________ | ||
| __________ | __________ | ||
| __________ | __________ | ||
| __________ | __________ | ||
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Credit card: VISA [ ] Euro/Master [ ] (JCB] |
Total Euro | __________ | |
Credit Card Number______________________________ |
Shipping | __________ | |
Expiration Date__________________ |
Amount Euro | __________ | |
Name of card holder:________________________________________ |
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| Signature of card holder:________________________________________ | |||
| Shipping address:________________________________________ | |||
| City: ______________________________ | Country:______________________________ | ||
| Date:____________________ | Signature:______________________________ | ||