Gift token

Fill in this form completely and click at the bottom of this page on "Send"

This information is mentioned on the voucher :
Receiver	(name or names)
Donor
on the occasion of
Value of the voucher	*(fill in an amount in Euro)*

Your details	*(where the voucher is sended to)*
Name
First name
Street and nr.
Postal code, Town
Country
E-mail	!
Tel. or Mobile

Date of gift

How do you wish to pay?	phone me up and ask for my creditcard-number (and expire date). I have filled in my phone number above. I transfer the amount to your bankacount and receive the voucher by post (or by e-mail if requested) Bank : FORTIS / account name Off-Road Factory B.V.B.A. BIC GEBABEBB / IBAN BE05 2800 7748 7475
Remarks

Cowboy Henk - Just me and my bike -

Groenedijkstraat 5a
8460 Oudenburg B E L G I U M
Tel. +32 (0)59 26 85 40
E-mail contact@grd.be
GPS: N51°11'30" E02°59'03"