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ORDER FORM 192 Last name: ........................................................... First name: ................................................................. Adress: ............................................................................................................................................................. ����������������������������������������������������������������������������������������������������������������������������������������������������������������������������� Zip Code: ............................................ CIty: . ............................................................................................... Country: ................................................................ Phone Number: ........................................................ Email: ......................................................................... Done in: ................................ On: ...................... 36 rue Vivienne 75002 PARIS - FRANCE phone: +33 (0)1 40 26 42 97 Email: contact@cgb.fr Website: http://www.cgb.fr/ Signature required Expiry date Cryptogram (last three digits on the back) Credit card number Bank transfer to Librairie-Galerie Les Chevau-Légers - CGF Bank: SG PARIS BOURSE IBAN: FR76 3000 3000 5900 0201 5160 581 BIC-SWIFT ADDRESS: SOGEFRPP Visa Credit Card Mastercard Credit Card Item No. (six figures) DESCRIPTION PRICE CUSTOMER No. SHIPPING FEES OVERSEAS AND WORLD: €12 AMOUNT