IDENTIFICATION Company : Name & First Name : Telephone : Fax : ADDRESS Street and Nbr : Post code : City : Country :

Which date : What time :

12h00 12h30 13h00 13h30 14h00 ---------- 19h00 19h30 20h00 20h30 21h00 21h30 22h00 22h30 23h00

Your mode of payment on the spot : CB/MASTER/VISA TRAVELLER'S CHEQUE CASH TRANSFER AT 30 DAYS (On Purchase Order)
Possibly, pls, indicate your internal order Nbr. (or ref.) in this box :

and SEND BY FAX TO +33 (0)1 45 35 77 34

Auberge Le Pot de Terre 75005 Paris - 22, rue du Pot de Fer - Tél. 01 43 31 15 51 / Fax. 01 45 35 77 34 / info@lepotdeterre.com