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Date: ____________
Name:
____________________________________
Address:________________________________________________________
Town / City: _________________________ State:____________
Post/Zip Code:_____________
Country: _____________________________
Ph: _______________________ Email:_______________________________________
Age: ______ Sex:
Male / Female Stance: Goofey / Natural
No. years surfing? 0-3
3-6 6-10 >10 please circle one
Are you: a recreational surfer /
a competitive surfer please circle one
Cost for Video Analysis:
Australian surfers: $220 + $15 postage
Total: $235-00
Rest of the World: $220 + $30 postage
Total: $250-00 [Australian dollars]
Payment method:
Visa / Mastercard / Bankcard please circle
one
Card Number:
_____________________________
Expiry Date: ____/____
Name on Card:
____________________________
Note: For orders other than from
Australia, personal cheques cannot be accepted. For overseas orders,
Bank drafts in Australian dollars is the only other payment method besides
credit card.
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