PURCHASE´S FORM

DATA TO BE FILLED IN

Name and Surname :

Address :

Town or City :

Telf :   Fax : E-Mail :

PURCHASE´S COST

Minimum purchase is 3.000 Pesetas or multiples of 3.000

Ptas

YOUR BANK ACCOUNT

State your bank account in which you would like to have your prizes lodged

La forma de pago sera CONTRAREMBOLSO