Complete and print the form below and send it with your cheque made out to:

BARTH Corp
23 Av de la Turquoise
1640 Rhode St Genese Belgique
Tel / Fax : 00 32 2 361 63 32

Your order will be processed as soon as payment is received and will be shipped to you by carrier.

Yes, I would like to receive :
Item ordered	Quantity	Unit price (€ including tax)	Amount
Lyre-Jet Family Comprising 1 system + 3 heads + 30 lengths of floss 1 year international guarantee
30 floss refills
Additional Lyre-Jet head

Postage costs
France (postage: € 31)
Europe (postage: € 45)
Total order Euros
Total order Francs