ORDER FORM

CUSTOMER DETAIL

*COMPANY NAME  
STREET
TOWN
POSTAL CODE
*VAT NUMBER  
*CONTACT PERSON  
PHONE NUMBER
* E-MAIL ADDRESS TO CONFIRM THE ORDER    

ORDER

*PRODUCTION FACILITY
*QUANTITY [t]
* TRANSPORT SERVICE
* TYPE OF PRODUCT
TYPE OF PRODUCTPRODUCTION FACILITYQUANTITY TRANSPORT SERVICE REMOVE

ADDRESS OF DELIVERY PLACE

* NAME OF THE PLACE Fill field: NAME OF THE PLACE
STREET
TOWN
POST CODE:
CONTACT PERSON
* PHONE NUMBER TO THE CONTACT PERSON Fill field: PHONE NUMBER
* DATE OF DELIVERY Fill field: DATE OF DELIVERY
* TIME OF DELIVERY Fill field: TIME OF DELIVERY
* TRUCK WITH COMPRESSOR
OPENING HOURS OF DELIVERY PLACE From
To
CONTACT PERSON
* PHONE NUMBER TO THE CONTACT PERSON
* DATE OF LOADING

INVOICE

* INVOICE DETAILS:

OTHER

COMPANY NAME
STREET
TOWN
POST CODE
VAT NUMBER
* PAYMENT TERMS
 All agreements are required
* We declare that the listed products are not purchased to be used or offered for sale or used for production of heat and that the purpose is none of the purposes specified
1) §45 par. 4 to 6 of Act No. 353/2003 Coll., on Consumption Tax, i.e., they are not purchased to be used, offered for sale or used for driving of engines, for the production of heat or production of mixtures specified in par. 2 of the above specified Act.
2) §45 par. 7 of Act No. 353/2003 Coll., on Consumption Tax, as amended, i.e., they are purchased to be used, offered for sale or used as an additive or filler for mineral oils intended for use, offered for sale or used for driving of engines with the exception of products that absorb water from mineral oils in tanks and fuel systems. * We declare that before loading we will inform ORLEN Asfalt Česká republika s.r.o. about the use of products for other than intended purposes and we declare that we are familiar with the GENERAL TERMS and CONDITIONS of SALE of ORLEN Asfalt Česká republika s.r.o. and COMPLAINT PROCEDURE, the newest versions of which are available at www.orlenasfalt.cz.