CASA Manual Order Form Hard copy forms can be ordered directly through the CASA Online Store at http://casa.gov.au/onlinestore If you prefer to place an order manually, please complete the details below and forward by email to [email protected] or fax to 03 9561 5911. Please be aware that orders that do NOT have an email address may NOT be processed. Personal Details * Please note that all fields marked with an asterisk are mandatory. BRN Benchmark may decline to process an order if mandatory fields are not completed Title *Given Name *Surname *Company Name (if applicable) *Postal Address *Shipping Address (If different to postal address) *Telephone Fax State Postcode State Postcode *Email Product Details (For a full list of product prices, descriptions and codes please see the following pages) *CASA Code Title/Description *Qty/UOM Unit Price (inc. GST) $ $ $ $ $ $ $ $ $ $ $ $ $ $ *Total Price Total + $15 Postage $ Payment Details • • • • Payment confirmation is required before goods can be despatched Please note that AMEX and Diners Cards are not accepted. All orders attract a delivery fee of $15.00 for any destination in Australia/internationally. CASA may decline to deliver items to an international address that cannot be verified If paying via electronic transfer, a remittance advice must be supplied to BRN Benchmark via email [email protected] or Fax 03 9561 5911. Payment via EFT Payment via Credit Card *Card Type: MasterCard Visa *Name *Card Number *Expiry Date / *Verification Number (3 digits located next to signature block on back of card) *Signature *Date / / Form 1001 05/2014 For payments using Electronic Funds Transfer (EFT) the bank account details are as follows; Bank: Commonwealth Bank Account Name: BRN Benchmark Pty Ltd BSB: 063-182 Account Number: 1119 3172 A remittance advice must be supplied to BRN Benchmark when payment is made CASA Manual Order Form Page 1 of 1