| Nom:_______________________________________________________________________ |
| Adresse:____________________________________________________________________ |
| Ville:_____________________________ |
Prov:___________________________________ |
| Code postale: ____________________ |
Téléphone:______________________________ |
| Courriel:_________________________ |
Payement: Cheque_____ Carte de crédit_____ |
| Visa/MC ______________________
Date d’exp_______ Signature___________________ |