Order Form

Item	Tog/Size	Unit Price	Quantity	Total Cost






Sub-total
Delivery Charge
Total Amount Payable

Please note that if you are paying by debit or credit card the name should be the same as on the card and the address the same as the statement address.

Title Mr Mrs Miss Ms other _________

Surname_______________________ Forename___________________________

Address____________________________________________________________

Town______________________________________ Country /

Region_____________________________

Postcode________________________

Country_____________________________________

Daytime phone number_____________________________________________________

(if paying by debt / credit card this must not be a mobile number)

Fax number______________________________ E-mail: _______________________________

Please indicate method of payment by marking the appropriate box:

· I enclose a cheque for £___________________________in payment of the above order

· I will pay by direct transfer to your bank account after I receive confirmation of order and order reference number. (Our account details will be advised to you with the confirmation of order)

· I authorise you to debit my card with the amount of £_____________________ in payment of the above order

Card type Visa Mastercard Switch Solo Visa Electron

Card number _______________________________Valid from (if shown)_______________________

Valid from (if shown)______________________ Issue number (Swith and Solo)_________________

Expiry Date_____________________________________________________

Signature:________________________________ CCV No. ___________________________

(if paying by Debit or Credit card this must be the signature of the Cardholder) (this is the last 3 numbers printed on signature strip)

Please FAX your completed order form to : 020-8883-5608

Order online www.lilysophia.co.uk with Lloyds TSB secure e-payment

Order Form

Item

Sub-total

Delivery Charge

Total Amount Payable