Remecare Ltd

Mail Order Form

Type in your information then print out this page and send it to:

Sales Dept. Remecare Ltd,
2a Tower Road, Worthing,
West Sussex, BN11 1DP.

Please include either your credit card details in the spaces below, or enclose a cheque or money order payable to "Remecare Ltd".

Name:

Address line 1: Address line 2:

Town/City:        County:

Post Code:
Tel.No. or e-mail:

Credit Card Number (if paying by credit card):

Credit Card Type (Visa, Master Card, etc):

Expiry Date: Last 3 digits on signature strip: Issue no. (if Switch):

Product Description Quantity Price(£)

Total:

Name:
Address line 1:	Address line 2:
Town/City:	County:
Post Code:	Tel.No. or e-mail: