Purchase order number:	Date:
To : ETC s.r.o. Rosinska cesta 8 01008 Zilina Slovak Republic Fax: +421-41-5652687	Company Name Post code Address Country Phone e-mail VAT number

Product type	Amount [pcs]	Price/piece [EUR]
Total:

Way of payment:

		Number of card Valid thru Card Validation Value / Card Verification Code

Name of cardholder
Address of cardholder
Sum of payment	EUR
Signature of cardholder

Please send the ordered devices to address:   (Do not fill in if the address is the same as above mentioned).

Important: This purchase order will be accepted (for safety of transaction) when the seller receive this order by fax or by post-mail in closed envelope. Orders sent by e-mail cannot be accepted. Please fill in this order completely in all rows, print them on your printer and send to fax number +421 41 5652687 or to the address of ETC written above.