number ordered: ___ @ $29.95:
number ordered: ___ @ $34.95:
Subtotal:
$3.20
Grand Total:
First Names:
Last name:
Preferred:
Street or Box listing:
Suburb:
City:
Country:
State:
Postcode:
Email:
Phone:
Preferred contact: [ ] Email [ ] Phone
(Please tick boxes that apply, enclose cheque or fill out credit card details - credit card orders can be faxed to: +64 4 972 7318)
I enclose my cheque / bill my credit card (delete which does not apply)
For total amount: NZD$_____.___
(Please make cheques payable to Rimutaka Incline Railway Heritage Trust)
[ ] Visa [ ] Mastercard
Name on card: ________________________
Card Number: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Expiry Date: _ _ / 2 0 _ _
Signature: ________________________