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PURCHASE ORDER

To address to

i2m
BP 200
14011 Caen Cedex
France

I wish to receive :

c one IDROSTAR, Price inc VAT and  port: .....................
c  one  i2mA, Price inc VAT and
port: .............................
c one  IOMAX4, Price inc VAT and port: .........................

Cheque # ..................Bank : ...........................

The material will be delivered to:

First Name : ....................... Last Name : ..........................

Address : .........................................................................

Zip/postal  I   I   I   I   I  City : ....................................


Country :..............................

Tel :.....................................

E-mail :............................................

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