First name:____________________ Last name:_________________________________
Address:________________________________________________________________
City/Town:____________________ Post Code:_______ State:_______
Country:___________________ Email:_________________________________________
Date:____________ Tel:__________________ Fax:_________________
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| Postage and Handling -
Australia - $5 first item & $2 each additional item to Max. of $15 New Zealand - $3 per item or email for exact postage costs. |
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| All purchases are subject to the Conditions of sale. | Grand Total | |||
Please make payable to White Eagle Lodge of Australia
Please circle the card type: Visa Mastercard
Card Number:__ __ __ __/__ __ __ __/__ __ __ __/__ __ __ __ Expiry Date:____/____
CCV No.:_______________ (last three numbers on back of card where you sign)
Card holder name:_____________________________________
Card holder signature:________________________________
Post or Fax to:
White Eagle Lodge - PO Box 225, MALENY, 4552, QLD, Australia.
Tel: + 61 (0)7 5494 4397 Fax: + 61 (0)7 5494 4169