DATE: 10/12/2012 REF. 23835/CA6
Mrs ❑ Miss ❑ Mr ❑
FAMILY NAME: KENSINGTON FIRST NAME:
PASSPORT Nb:
DATE OF BIRTH:
SHIPPING ADDRESS:
HONG KONG
TEL. Nb: FAX Nb:
EMAIL ADDRESS:
I hereby give to HERMES SELLIER my authorization to charge my credit card for the amount of:
(n/tans
L 326 €
(in k&n)
Product description: Shoulder strap, in black box, with palladium hardware
O AMERICAN EXPRESS (*) Nb
Security Code (compulsory) :
(4 figures right hand side — face of card)
O J. C. B. Nb
SIGNATURE:
EXPIRY DATE
(EUROCARD, MASTERCARD and VISA are not acceptedfor mall order)
(*) FOR PAYMENT BY AMERICAN EXPRESS CARD WOULD YOU PLEASE
CONTACT THE AMERICAN EXPRESS CENTER OF YOUR COUNTRY TO
CONFIRM THE PURCHASE.
=> We would like to draw your attention to the fact that various duties may be
claimed by your Customs authorities on arrival of the goods in your country.
EFTA00557252