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   CANESHOP
   Sevice commande, 63 route de Lezoux

   63190 ORLEAT    FRANCE


   TEL : + 33 4 73 68 26 10  - FAX : + 33 4 73 73 20 44
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   Name :					Christian name :

   ADDRESS : 

   ZIP CODE : 		City :

   e-mail :                                                TEL (permanent ) :
 
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  ADDRESS OF DELIVERY IF DIFFERENT ::


			


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     REF.      QUANTITY              DESIGNATION            UNIT PRICE      RISING

  
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                                                                                                                     TOTAL       |__________


                                                                                                  Expense of Port    |______________|

        

                    			                  NET TO PAY :        |______________|

   This order will be taken into account only accompanied by
   its entire regulation.





   REGULATION BY :

    [ ] Letter Mandate
  			
    


    

    Date and Signature :