Name of Customer:______________________________
Invoice / Order No:_______________________________
Physical Address:________________________________
_______________________________________________
_______________________________________________
Telephone No: (____) _____________________________
Fax No: (_____) __________________________________
E-Mail Address:__________________________________
Port / Airport to which goods must be consigned:
_______________________________________________

Documents to be couried to: (If different to physical address)
Name:__________________________________________
Address: ________________________________________
_______________________________________________
________________________________________________
Telephone No: (_____) _____________________________
Fax No:( _____) __________________________________
E-Mail Address:___________________________________

Customer Signature: _______________________ Date: ________________________

PLEASE NOTE:

• Shipment is to Port / Airport as specified
• All clearing and onward transport costs are for customer's account.