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Order Form
Fasthosts and UKreg logos
1. Contact information

First name

  

Last name

  
House / Flat number  
Street name  
Town / City  
Post code  
County  
Email address  
(e.g. yourname@your-domain.co.uk)
Daytime phone number  
(Area code)                (Phone number)
Where did you hear about us?  
2.Quantity
Quantity
Price Per Unit
P&P
     
Total Cost
3. Payment
I wish to pay by  
Cheque made payable to Varyflush Ltd
   
or Credit/Debit Card
  
Card Number  
Expiry Date   /
 Issue Numer
(switch or delta)
  
Start Date   /  
Signature  
Date
DD      MM       YYYY
Complete this form and send it to:
Varyflush Headquarters, Philiproyd House,
55 Calder Road, Mirfield, West Yorkshire
WF14 8NP

Or fax it to: 01924 500 510
 For office use only:
Date Received ____________________________
Order number _____________________________
Comments


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