COELACANTH INVENTORY ORDER FORM

Please send me ............... copy/ies of the new Coelacanth Inventory @ R75.00 per copy + postage (TNT) @ R 6.25 per copy in South Africa; R36.00 for North America; R44.00 for Europe and R50 for Australia and the Far East.

Name: ..........................................................................................

Institution: ....................................................................................................

Postal address: ...........................................................................................

....................................................................................Post code ......................

Contact telephone number: ..............................................................

e.mail: ...................................................................................................

Method of payment: please mark appropriate box with ‘X’

□ Credit card                                                                                        □ Electronic funds transfer      □ Direct deposit            □ Other (Specify)

Banking details

Account Name: South African Institute for Aquatic Biodiversity

Bank:               ABSA

Branch:            Grahamstown

Branch code:   420517

Account no:     40-4922-9976

SWIFT code:   ABSAZAJJ                                           Please give reference: ‘coelacanth’ + surname

For credit card payments, please fill in details below

Name on card □□□□□□□□□□□□□□□□□□□□□□

Card Type: VISA □   MASTERCARD □ (We regret we cannot accept Diners Club or American Express payments)

Card number: □□□□□□□□□□□□□□□□

CVV number : □□□ (Last three digits on back of card)    Expiry date □□□□

Total amount to be collected: ZAR □□□□.□□                                                             Month/year

Transaction reference: ‘coelacanth’ + surname

I hereby grant permission for SAIAB to retrieve funds as detailed above

Cardholder signature: .......................................................               Date □□□□□□□□

Send order form and proof of payment to:

Hanoria Kalimashe: library@saiab.ac.za       or Fax +27 (0)46 422 2403

Mail: Ms H Kalimashe, South African Institute for Aquatic Biodiversity

Private Bag 1015, Grahamstown, 6140 South Africa.