SEND ORDER TO Surname __________________________________________ First Name _________________________________ Address _______________________________________________________________________________________ City ______________________________________________ Postal Code _______________________________ Country ___________________________________________ Point Relais ID Number ____________________________ Telephone mobile (requested by all the transporters) ___________________________________________ Email __________________________________________________________________________________________ Payment   __/ Chèque   __/ Visa   __/ MasterCard Card # __/__/__/__/   __/__/__/__/   __/__/__/__/   __/__/__/__/ Exp. date __ __/__ __     Last 3 numbers on the back of the card __/__/__/ Signature