				ORDER FORM


Invoice Address				Delivery Address (If different from invoice)

Name:				Name:

Establishment Name:				Establishment Name:

Address:				Address:



Postcode:				Postcode:
Telephone:				Telephone:
Fax:				Fax:
E'mail:				E'mail:


If you wish to pay by credit/charge card, please complete the following details Pre-paid orders - Free delivery		Cardholders Name:
		Card Type (e.g. Visa/Delta)
		Security Number:
		Card Number:
		Start Date:
		Expiry Date:
		Issue No. for Switch:

Special Instructions
For Order :-


Item Code	Description	Colour/Size	Unit	Quantity	Unit Price	Total Price









					Goods Total
					Carriage	£5.50
					VAT @ 17.5%
					Total

Hemming Healthcare, 91-93 Bailiff St. Northampton. NN1 3EA E-mail: info@hemmingva.com
Fax 01604 620002 Call 01604 634289
Hemming Healthcare is a trading name of Hemming Visual Aids Ltd.
Company Registration no: 1941181