Yes, I would like to purchase a copy of the film Password Women by tamir13

VIEWS: 36 PAGES: 2

									ORDER FORM                      FILM PASSWORD: WOMEN

Print this form and send it:
    -    by fax to: +31-(0)20-6655812
    -    by mail to: IIAV / PR Dept. / Obiplein 4 / 1094 RB Amsterdam / The Netherlands




Your Order

❑       …… VHS copies of Password: Women at € 15,- (including € 2,50 mailing costs).
        Format*:   ❑ VHS-PAL      ❑ VHS-NTSC        ❑ VHS-Secam
        Subtitles*: ❑ Spanish     ❑ English

❑       …… DVD copies of Password: Women at € 19,- (including € 2,50 mailing costs).
        The DVD is only available in PAL.
        Subtitles*: ❑ English/Dutch ❑ English/Spanish

* Check the format/subtitles you want to order!



Your Personal Details
Address to which the film is to be sent

Last name*:                     …………………………………………………... f/m*
First name*:                    …………………………………………………………
Organisation:                   …………………………………………………………
Address - street & number:      ……………………………………….. work / private*
Post/zip code:                  …………………………………………………………
City:                           …………………………………………………………
Country:                        …………………………………………………………
Telephone:                      …………………………………………………………
E-mail:                         …………………………………………………………




    International Information Centre and Archives for the Women’s Movement (IIAV)
                        IIAV - Obiplein 4 - 1094 RB Amsterdam - The Netherlands
         Phone+31 (0)20-6651318 - Fax +31-(0)20-6655812 – Email pr@iiav.nl - Internet www.iiav.nl
Your Payment
Check a means of payment

     By credit card

          VISA
          Eurocard Mastercard
          American Express Europe Ltd

           Card number: |__|__|__|__| |__|__|__|__| |__|__|__|__| |__|__|__|__|

           Date of expiry: __ __/ ______ __ (month/year)



           Signature:_________________________________________________________

           Last 3 figures of the number on the back of your credit card:      __ __ __

           Name (as it appears on your card): ……………………………………………………

           Address (at which the card is registered): ……………………………………………

           Post/Zip Code: …………………………………City:…………………………………….

           Country: …………………………………………………………………………………..

     By bank

       Please transfer the correct amount to:

           Organisation:     IIAV
           Bank name:        Postbank
           Address           Amsterdam, The Netherlands
           Account number: 6727720
           IBAN:             NL72 PSTB 0006727720
           Swift code (BIC): PSTBNL21

           Mentioning: ‘Film Password: Women’




As soon as we have received your payment, we will send you the film Password: Women.

The IIAV is registered at Stichtingregister Kamer van Koophandel Amsterdam: 207.419
VAT number: 0086.08.362.B.01.

We are sorry; the IIAV cannot accept bank cheques.



   International Information Centre and Archives for the Women’s Movement (IIAV)
                       IIAV - Obiplein 4 - 1094 RB Amsterdam - The Netherlands
        Phone+31 (0)20-6651318 - Fax +31-(0)20-6655812 – Email pr@iiav.nl - Internet www.iiav.nl

								
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