1. Print this form and
2. Fill in data with a (black) pencil
3. Send it as a fax to +31-518-490010 or by mail delivery to Accordéon Mélancolique, Georg van Saksenstraat 3, 9079 KE Sint Jacobiparochie, the Netherlands.
The order will be despatched by return.
For questions please contact +31-518-490028, fax: +31-518-490010 or email info@acmel.nl

1 CD costs EURO 17,- world wide, including postage and packing.

Number of "Les Invités" : ____________________________
Number of "Le Nid Aimé" : ___________________________
Number of "Petits Fours Frais" : _______________________
Number of "Parade des Poules" : ______________________
Number of "L'imparfait du Coeur" : ___________________
Number of The Reykjavic Accordion Festival 2003__________
Number of "Le Roi des Jongleurs". : _____________________
Number of "Django Chanté" : __________________________
Number of "Laughin' in Rhythm" : ______________________
Total number of CDs. : ______________________________ x euro17 = _______
Number of booklets "lyrics of Django Chanté" ____________ x euro 5 = _______
Number of booklets "lyrics of Le Roi des Jongleurs" ________ x euro 5 = _______
Number of Sheet Music book "Parade des Poules"________ x euro 18 = _______
Number of Sheet Music book "L'Imparfait du Coeur"_____ x euro 18 = _______
Number of Sheet Music book "Le Nid Aimé"____________ x euro 18 = _______
Total Amount in EURO: ..........................................................................._________

Please mark with a cross - O American express - O Diners club

Card number: _______________________________________________________

Expiration date: _______

Name: _____________________________________________

Address: ___________________________________________

City and code: _______________________________________

Country: ____________________________________________

Signature: __________________________________________

Your email address: ________________________________ (optional / to confirm your order)