Company Name / Organisation Name / Full Name  ______________________________________________________

address _______________________________________________________tel. ____________________________

VAT number /Fiscal code (in the event that an invoice is required) __________________________________________

would like to order_____copies of the publication Toscana Mater by Mario Luzi at a price of 40 euros each (4% VAT included) plus 8 euros freight for each copy, total amount ________________________ euros.
Discounts are available for reservations of large numbers of copies, which may also be customised (subject to prior arrangement). The payment must be made by credit card (VISA or MASTERCARD)
Credit card number _______________________________________
Expiry date _____________________________________________
Holder’s date of birth _____________________________________

The books will be delivered directly to your office/home by December 10th 2004.
 
Special requirements ____________________________________________________________________________

date _____________________ stamp and signature ___________________________________________________

Form to be cut out and sent to:
INTERLINEA EDIZIONI, VIA PIETRO MICCA 24, 28100 NOVARA, TEL. 0321 612571, FAX  0321 612636,
E-MAIL: EDIZIONI@INTERLINEA.COM