Ponte Morosini 41 - Genova - Italy
tel. +39 010254681 fax +39 0102546800
e-mail: support@gsy.it
info server: www.gsy.it

This order form is to be filled and faxed to +39 010 2546800 or posted. Please do not send orders and credit card numbers via e-mail.
Please type your data and select File | Print from Netscape menu. Do not print the form and hand-fill the form.

First name: Last name:
Company: Address:
Nation:
Phone number: Fax number:
E-mail address:
I here formerly order the following item:
N. copies of Network Juke Box .
For a total amount of: $ USD plus VAT amount (see above):
Note: Pls add 16% tax (VAT) if:
  • Ordering from Italy
  • Ordering from EEC and buying as private individual (not representing a company)

Payment method

Please charge my credit card
  Credit card number:
  Credit card provider: Visa     MasterCard
  Expiration date:



I will credit the money via fund transfer to:
  GeneSYS Informatica S.r.l.
  Banca Commerciale Italiana
  Sede di Genova
  Account N.1111952/01/84 CAB: 01400 ABI:2002



I enclose money check to:
  GeneSYS Informatica S.r.l.

Signature:.........................................................