
Layout 20130101
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www.diagnostics.be
Langdorp • Belgium •
T
el: ++ 32 16 44 63 89 • F
ax: ++ 32 16 44 77 62 • e-mail: c
[email protected]
ISO 9001:2008
ISO 13485:2003
Order form
Forward to our local distributor
or fax it to + 32 16 44 77 62
to enjoy your special promotions!
Yes, I would like to order
Please send me a quote
Code Product Quantity Notes
Invoice to:
Company:
Department:
Contact:
Address:
City & Post Code:
Country:
Tel:
Fax:
e-mail:
Ship to:
Use same as invoice to
Company:
Department:
Contact:
Address:
City & Post Code:
Country:
Tel:
Fax:
e-mail:
Date: Signature: Stamp:
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