The Grasshopper Order Form

Please print out this form and fax it to +31-20-6279819

or mail it to:

The Grasshopper
Oudebrugsteeg 16
1012 JP Amsterdam, Holland

NB. We cannot accept order forms which are not completely filled out and signed.


Name : ...................................................
Surname : ..............................................
Street : ....................................................
ZIP Code : ..............................................
City : .......................................................
Country : ...............................................
E-mail : ..................................................
Tel. : .......................................................
Fax. : .......................................................

________________________________________________________________

Hereby I order the following articles:
Article Description Size Price

1) ................................. .... DFl. .........
2) ................................. .... DFl. .........
3) ................................. .... DFl. .........
4) ................................. .... DFl. .........
5) ................................. .... DFl. .........

Subtotal: .........

________________________________________________________________

(All prices include VAT, exclude P&P)
P&P cost: P&P: .........
Holland DFl. 11,- Total: .........
Europe DFl. 15,-
World DFl. 25,-
Signature: ..............................
________________________________________________________________

I will pay by:

Credit Card: o Eurocard o Mastercard o American Express o Visa

Card number: .... .... .... ....
Name as printed on the card: ..............................
Expiry Date: ....../....../ ......

Signature: ..............................

________________________________________________________________

Cash:
Send the total amount due together with this order form BY REGISTERED MAIL
ONLY to:

The Grasshopper
Oudebrugsteeg 16
1012 JP Amsterdam, Holland
________________________________________________________________