Customer Information

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Bill To Information

Company Name

Title

none Mr. Mrs. Dr. Prof.

First Name*

Last Name*

Middle Name

Address 1*

Address 2

City*

Zip/Postal Code*

Country*

Select Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria (Endkunden, Firmen ohne UStIdNr) Austria (Firmen mit UStIdNr.) Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegowina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote D'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia (Companies w/ VAT Nr.) Estonia (End Consumers, Companies w/o VAT Nr.) Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France (companies w/ VAT Nr.) France (end consumers, companies w/o VAT Nr.) French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany (Firmen mit UStIdNr.) Germany (Firmen ohne UStIdNr.) Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-bissau Guyana Haiti Heard and Mc Donald Islands Honduras Hong Kong Hungary (Companies with VAT Nr) Hungary (end users, companies w/o VAT) Chad Chile China Christmas Island Iceland India Indonesia Iran (Islamic Republic of) Iraq Ireland (Companies with VAT) Ireland (End users, companies w/o VAT) Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia, The Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland (Endkunden, Firmen ohne UStIdNr) Poland (Firmen mit UStIdNr) Portugal (companies w/ VAT Nr.) Portugal (end consumers, companies w/o VAT Nr.) Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia (Slovak Republic) Slovenia (Companies w/ VAT Nr.) Slovenia (End Users, Companies w/o VAT Nr.) Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain (Firmen mit UStIdNr.) Sri Lanka St. Helena St. Pierre and Miquelon Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania, United Republic of Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom (Companies with VAT Nr.) United Kingdom (Consumers, Companies w/o VAT Nr.) United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City State (Holy See) Venezuela Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wallis and Futuna Islands Western Sahara Yemen Yugoslavia Zaire Zambia Zimbabwe

Phone*

Mobile phone

Fax

Company ID

VAT Nr.*

WWW

Skype

Forecast - # of valves/year

Forecast - average # of valves/month

therefrom 12V valves (in %)

Birthday

Bank Account Info

Account Holder

Account Number

Bank sorting code number

Bank Name

Bank Account Type

Checking Business Checking Saving

IBAN

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