Please provide your name and address in the fields provided.
The phone number will also be put on the address label to facilitate delivery; make sure it is a number where you can be reached during daytime.
!!! IMPORTANT: DUE TO TECHNICAL PROBLEMS YOU CANNOT SEND THIS FORM VIA A SUBMIT BUTTON. PLEASE MAKE A SCREEN PRINT AND SEND IT TO ME VIA EMAIL (paul.shirley[at]ziggo.nl). Sorry for the inconvenience. !!!