SEND YOUR ORDER TOGETHER WITH THE TOTAL AMOUNT SHOWN BELOW TO:

POSTBUS 3019
1270 EA
HUIZEN (N/H)
HOLLAND

Name                   : 
Adress                 : 
Zip Code               : 
City                   : 
Country                : 
 
Order ASF     Jackpot  : Y
Order Awesome Jackpot  : Y
 
Disk size              : 1.44
 
Do you live in Holland : N

Order ASF     Jackpot  : $ 20,-   (Including VAT, No postage)
Order Awesome Jackpot  : $ 15,-   (Including VAT, No postage)

Total $ 30,-   (Including VAT, No postage)



Signature :
