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ORDER FORM 192 Last name : .......................................................... First name : ................................................................ Adress : ............................................................................................................................................................ ����������������������������������������������������������������������������������������������������������������������������������������������������������������������������� Zip Code : .......................................... CIty : ............................................................................................... Country : ............................................................... Phone Number: ........................................................ E-mail : ................................................................... Done at : ................................ The : ...................... 36 rue Vivienne 75002 PARIS - FRANCE Téléphone : 33 (0)1 40 26 42 97 E-mail : contact@cgb.fr Internet : http://www.cgb.fr Signature required Expiration date Cryptogram (last three digits on the back) Credit card number Bank transfer Librairie-Galerie Les Chevau-Légers - CGF Bank : SG PARIS BOURSE IBAN: FR76 3000 3000 5900 0201 5160 581 BIC-ADRESSE SWIFT : SOGEFRPP Credit Card Visa Credit Card Mastercard MasterCard N° (six figures of the item) DESCRIPTION PRICE CUSTOMER N° SHIPPING FEES OVERSEAS AND WORLD : 12€ AMOUNT