Accelonix new customer form Please fill in below form as complete as possible, fields marked with (*) are required. ------------------------------------------------------------------------------------------------------- Email address to validate a successful form subscription(*) -------------------------------------------------------------------------------------------------------- DELIVERY ADDRESS: Company name (*) Department (*) Contact name (*) Street (*) Zip Code (*) City (*) Country (*): NetherlandsBelgiumLuxembourg Phone number (*) Email address for order confirmation (*) Website -------------------------------------------------------------------------------------------------------- INVOICE ADDRESS: Company name (*) Department (*) Contact name (*) Street (*) Zip Code (*) City (*) Country (*): NetherlandsBelgiumLuxembourgOther Other : Phone number Accounting department (*) Email address for digital invoice(*) VAT number(*) CoC number(*) -------------------------------------------------------------------------------------------------------- BANK DETAILS: Name of Bank IBAN no(*) BIC/Swift code -------------------------------------------------------------------------------------------------------- REMARKS: -------------------------------------------------------------------------------------------------------- * A confirmation will be send to your e-mail to validate a successful form subscription, In case you did not receive confirmation e-mail please refill the form again or contact Accelonix directly.