Cefaly and Electrode Order Form

Date:

Customer-Nr.:

Buyer

First Name:

Last Name:

Country/City:

Address:

Zip:

Phone Number:

Landline:

Mobile:

E-Mail Address:

Order

Price

Toman

Quantity

Total

Toman

Cefaly-Set

395.000,--

Cefaly-Set with Doctor prescription

370.000,--

 Kit 3 Electrodes

24.000,--

Delivery cost

Total amount to Pay:

Payment

Please tick, where applicable:

□ Cash

□ Card to card to Nr.  6393 4711 1102 0025

□ Bank transfer to account Nr.      233 – 800 – 1102002 – 1     Bank Pasargad

Sales agency

EPA, Electro Pezeshk Abzar Co.Ltd.

Tehran - Vanak square, Ghandi shomali, No.8,  5th floor, unit no.20

Tel. +98 (0) 21 – 88 654 984

                          88 87 6174

Fax +98 (0) 21 – 88 77 8994

e-Mail: sardard.ir@gmail.com                             www.sardard.ir

Signature

Date