| interconnections Schillerstr. 44
D - 79102 Freiburg
Germany
Tel. +49 761 700 650, Fax - 700 688
info@au-pair-box.com
Version of Jan. 2nd 2007
Application Form for
the "Au-Pair-Box"-Service
I wish to benefit of the "Au-Pair-Box"-Service.
I have knowledge of the "Service-Description" as well as
of the "General Terms and Conditions of Business" and filed
them. The fees have to be paid on the basis of the actual price list.
I understand that agencies with several offices pay € 11,90 for any
more postal address on the agencies´ list or email address on
the mailing list respectively. All prices include VAT, momentarily
19 %, if applicable. Else prices are gross for net.
| Prices in
Euro incl. VAT
(in EU-Countries) |
Offer 1 |
Offer 2 |
Offer 3 |
| Installation
fee (once and for all) |
--- |
59,50
|
119,00 |
| Monthly fee |
13,09* |
30,94** |
48,79 |
* Anual prepayment. ** 6 months´ prepayment.
__________________________________
Company,
Organisation |
__________________________________
Telephone |
__________________________________
Person in charge |
__________________________________
Fax |
__________________________________
No./street |
__________________________________
Email |
__________________________________
Postal Code, Town |
http://______________________________
Homepage, Address for a Link |
| I
am interested in: |
| Offer
1 O |
Offer
2 O |
Offer
3 O |
Name of the subdomain under http://www.au-pair-box.com
(compare "Service-Description" here).
My internet adress shall be named as follows:
_____________________________________________________________
Town, Date, Signature, Stamp |
I wish to
pay by:
O Check
(in Euro !,
plus Euro 15 bank fees for any one check
__________________________________
Name of the bank
__________________________________
holder of the account
__________________________________
Bank code
__________________________________
account number
Should my account not be credited,
my bank is not obliged to make any payments.
|
O Credit Card
I declare that the following details are correct
and that I shall pay the fees which are due to interconnections
for the utilisation of the Au-Pair-Box-Service.
__________________________________
Card holder (Name, first name)
__________________________________
number of card
__________________________________
Valid until (month/year)
O Visa, O Eurocard, O Mastercard,
O American Express, O Diners Club
__________________________________
Bank
This agreement is valid until notice
of termination in writing (Registered letter with reply coupon).
Fees are always due in their totality.
|
______________________________________
Town, Date, stamp, signature of account holder |
_______________________________________
Town, Date, stamp, signature of credit card holder |
|
|
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