Invoice address
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Company name *
VAT number (*)
Foreign customers without VAT-number pay
Belgian VAT (21%) without retroactive effect.
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Address *
Postal Code *
City *
Country *
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Delivery address
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Please check this box if the delivery address details are the same as the Invoice address details.
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Company name
VAT number (*)
Foreign customers without VAT-number pay
Belgian VAT (21%) without retroactive effect.
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Address
Postal Code
City
Country
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Contact details
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Shop Details
Shop phone
Shop fax
Shop e-mail
Shop website
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Shop Owner
Shop owner name *
Shop owner e-mail
Shop owner phone or mobile *
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Shop Manager
Shop manager name *
Shop manager e-mail
Shop manager phone or mobile *
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Shop Accountancy Responsible
Shop accountancy responsible name *
Shop accountancy responsible e-mail
Shop accountancy responsible phone or mobile *
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Payment information
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Wire transfer
Credit card (fax or mail us CC details)
LCR (France only) (fax or mail us RIB code)
BANKEINZUG (Germany only) (please send original by post or fax)
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IMPORTANT !
After sending us this form, it is important that you FAX or MAIL us your CREDIT CARD, LCR or BANKEINZUG document, otherwise we cannot process your application.
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Additional information
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What type of Shop do you have ? *
shop only
shop + internet shop
internet shop only
Distribution
I am a distributor of the following brands
Do you want to receive our catalogue and price lists ? *
yes
no, I received them already
Do you want to receive our newsletters ? *
yes
no, I received them already
Do you want to receive B2B login & password *
yes
no, I received them already
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Opening hours
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MONDAY
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TUESDAY
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WEDNESDAY
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THURSDAY
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FRIDAY
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SATURDAY
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SUNDAY
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Spoken languages *
Remarks/Questions you might have
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