Miss   Mister
First Name:*
 
Last Name:*
 
Street:*
 
Country:*
 
ZIP:*
 
City:*
 
Phone:
 
Email:
 
Fax:
 
   
  Order of
  x Bags Gold-Ash-Powder Pills (Bag with 100 Pills, 50 € per Bag)
  x Gold-Ash-Powder Capsules (50 € per Capsule)
   
  Please transfer the enire amount, plus 9 € mailing expenses, to this Account:

U Shein Sayagyi
Oberbank AG
Zweigstelle Mondsee
Schloßhof 1 b
A-5310 Mondsee
BLZ: 15120
Konto-Nr: 4051-0253.46
IBAN: AT65 1512 0040 5102 5346
BIC: OBKLAT2L

After the receipt of money the Gold-Ash-Powder will be sent by registered mail.

I will transfer the entire amount of €.