THANK YOU TO FILL A FORM UP BY PRODUCE
  
ENAMEL
LAVASTONE
PLATE
In order to allow us effective research and/or the creation of your own blazon, please fill up the questionnaire below.
THE MODEL OF YOUR BLAZON WILL BE SUBJECTED BEFORE MAKING YOUR ENAMEL LAVASTONE PLATE.
YOU MUST FILL THE INDICATE * BOXES UP.
 
  NAME to which the blazon must refer itself*:    
REGION, PROVINCE, COUNTRY, of origin of your family, if you know it*:
PROFESSIONAL ACTIVITY to which the blazon could be refered, yours or that of your family:
Please specify if you think of having affinities with particular elements, such as animals, plants, minerals, planets...:
  DÉCORATIONS, military decoration, civil and/or military quotation:    
Research/Creation and postal expenses included.
   IMPORTANT: If you already got your own crest, click HERE for us to send them by Email (drawing or description).      
I READ AND ACCEPT THE TERMS OF SALE
PLEASE CHECK THE BOX*
  Please, INDICATE here all specified which would seem possibly useful to you for the creation of your blazon:    


CHOOSE THE ENAMEL STELL PLATE

BLAZON CUT
AT THE FORM
30 cm x 20 cm
350.- Euros

BLAZON CUT
AT THE FORM
40 cm x 30 cm
590.- Euros

BLAZON
30 cm x 20 cm
290.- Euros

BLAZON
40 cm x 30 cm
530.- Euros


PARTIAL PAYMENT WITH CREDIT CARD
In order to open your file, you will have to pay by credit card a partial amount of : 50.- Euros
The balance will have to be paid by bank tranfert via the bank address below
In order to know the currency rates, please consult the following website : http://www.oanda.com

 
CARD HOLDER'S NAME :
 
 
We only accept VISA CARD or MASTERCARD
 
  Card Number* :  
   
Expiration date* : /
 

BANK TRANSFERT
Bank Name :
   BANQUE POPULAIRE
Bank address :
   18, Grande Rue de Vaise
Bank address :
  69009 Lyon - FRANCE
Company Name:
  GENERALDRY - GRAPHISTYLE
Account Number :
   00201122363
IBAN (Int'l Bank Account Number) :
   FR76 1390 7000 0000 2011 2236 368
BIC (Bank Identification Code) :
   CCBPFRPPLYO


DELIVERY ADDRESS
Name and Surname :
  
Address 1 :
  
Address 2 :
 
Zip Code :
 
City :
  
State :
  
Country :
  
Email address* :
  
Telephone :