Title  Mr. Mrs. Ms. Miss Sr. Sra. Srta. Herr Frau Frn Mme. Mlle.  First Name   Surname(s) 
Tax Number (CIF)    Code  (You must include this code number)
Company Name  Street Address 
City    Province/County 
Postal Code    Country 
Phone    Fax    Email 

Phone numbers I will call from (please include country code, e.g. 34 for Spain, 44 for UK):
       

Billing Address (only if different)
Company  Street Address 
City    Province/County 
Postal Code    Country 

Bank Information (Account must be in Spain)
Bank Name 
Bank Code ("Entidad")    Branch Code ("Sucursal")    Control ("DC") 
Account Number ("Cuenta")  (10 digits - start with zeros if necessary)
Exact Name of Account Holder 

Credit Card (only charged if bank debit fails)
Billing Currency  British Pound DeutschMark Dutch Guilder Euro Spanish Peseta   Type of Credit Card  American Express Euro/MasterCard Visa  
Exact Name on Credit Card 
Credit Card Number    Expires 

Additional Information
Language  Deutsch English Español   Invoice sent by  email mail   Where did you hear of us?  Print Advert Radio Letter Flyer Friend In the press

 

I authorize Vicom to charge all calls to the above bank account, or failing that, to the above credit card.

Bank account holder's signature __________________ Credit card holder's signature _______________________

Don't forget to print and sign then fax or mail form!
Vicom, Apartado 205, 07181 Palma Nova, Baleares, Spain Tel: +(34) 971-677469    Fax: +(34) 971-676822