| Name: Mr/Mrs/Miss/Ms*
_____________________________________________________________ Address:
_________________________________________________________________________
___________________________________________________________________________________________
Telephone Number (include Country code and STD/area code):
______________________________________________
e-mail address(es):
_________________________________________________________________
Please supply the following
Bear(s): ___________________________________________________
I enclose a Deposit/Balance*
Cheque/Money Order* for £ __________________________________
(*please delete as
applicable).
Signature:
____________________________ Special Instructions:
_________________________
Date:
________________________________
_________________________ |