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www.rootspoland.com APPLICATION FORM = INDIVIDUAL ITEM/SUPPORT/... PAYMENT


www.rootspoland.com NUMBER/item/payment:*

(kindly ask all to state that number if needed with all further correspondence reffering to this point)

 / 2011

Client's Name/Data:*

Client's E-Mail Address:*

(to send all correspondence/reports/records/information...)

Client's Postal Address*:

Individual query/item/support/payment amount:*

(other services/surplus payment/different items/...!)

Please note - all payments are effected finally in PLN-Polish Zloty as an equivalent of $...or...

Please Select One!

Please write! ( e.g. 25 ) 

= the amount registered will be calculated to and settled in PLN - Polish Zloty via secure credit card system - please follow fulfilment ; if requested via bank transfer - please use www.rootspoland.com  bank account data and inform in Message below.

Fees paid from other currency have to be calculated to Polish Zloty (PLN) according to National Bank of Poland exchange rate, announced each business day on this website.

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Others - e.g. Webmoney systems etc. - please state in message below.

Message:*

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by Tadeusz - Tad & friends