PSYSHOP.NET - INTERNET MUSIC WHOLESALE TRADE
CUSTOMER REGISTRATION

Dear customer!
Please print this form and fill in all details.
Fax it together with a copy of your business registrataion
to the fax-number below. Kind Regards, Psyshop.net, J. Roy

Company name:________________________________________________

VAT (if available):__________________________________________

Owner / Manager:_____________________________________________

Phone:_________________________ Fax:_________________________

Email:_______________________________________________________

Internet:____________________________________________________

Address:_____________________________________________________

        _____________________________________________________

Zip / Postal Code:___________________________________________

City:________________________________________________________

Country:_____________________________________________________

Invoice address (if different):

        _____________________________________________________

        _____________________________________________________

Please select your prefered method of payment:

__Bank transfere

__C.O.D. / Cash on delivery (some european countries only)

__Credit Card (VISA, Mastercard, Eurocard)

  Card Number:_______________________________________________

  Expiration Date (mm/yy):___________________________________

  Card Owner:________________________________________________

  Card Validation Number (CVV/CVC, three digits):____________

Date/Stamp/Sign:



(Info e-mail: info@psyshop.net, fax: +49 8142 593165)