Please complete
the details below and post / fax (01458 445 988
) to: 'Disabled Accessories, The Tanyard, Leigh
road,
STREET, Somerset, UK, BA16 0HR.'
Order / Delivery Details
Name:
Card holder Address:
Delivery Address (If different):
Post Code:
County / State:
Country:
Post Code:
County / State:
Country:
E-mail Address:
Telephone No.
Ref No.
Product(s)
Price
Qty
Subtotal
£
£
£
£
£
£
£
Postage & Packing
:
Grand Total :
£5.45
If you are claiming
VAT Relief (click
here for more information) on your order please
complete the section below:
I...................................................
of the address shown below declare
that I am disabled and suffer from
(describe condition)......................................................................and
that the goods I am purchasing are
being provided for my own personal
use. I claim relief from VAT on qualifying
products under Group 12 of schedule
8 to the VAT Act of 1994.
Note: It is an offence
to declare false information.
Payment
Method:
Visa
Mastercard
Switch
Solo
Delta
Cheque
- Made payable to 'disabledaccessories.com'
Card Number: _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Expiry Date (mm/yy): _ _ / _ _
Issue No. (Switch / Solo): _ _ _
Security Number (3 digit number on reverse
of card): _ _ _
Your signature:
................................................................................
I authorise Foot Shop Ltd to charge my
credit/debit card with the above amount.
