Date of Birth..1 February 2003..................... Fax.: .................................... .
Email: ksenia.spunt@gmail.com.
Sex: male female Date of your next visit in the institut
It is very important to give this date!
November 2015
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Mothers name.Ksenia Shpunt...........................
Fathers name ................................................
Shipping-address ..........................................................................
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St Petersburg
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Lenina street 52 flat 13
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Country ..........................................................
Russia
A) Vest
Each vest will be fitted to the measurements of your child. Please provide exact measurements. Write down the measurements on the included page. The vest is adjustable by one size, thereby guaranteeing, that it will fit your child longer.
A) control box
The control box works between 80 and 240 volt. The controlbox does regulation the voltage self, which you need for your country. The device with serial-number 7002038
Type AH3 is CE-conform.
C) Compressor
The compressor works very quiet and is very small (weight; 4, 8 kg, size 0, 20 x 0, 15 x 0,15). The compressor works very good with the vest and control box together it is very comfortable for the childrens to sleeping in the night. .
Items to be delivered please fill out
□ 220 Volt 50 Hz □ 110 Volt 60 Hz
Number price Description of
of pieces intern
compressor
adjustable breathing
vest
control box 1,
control box 2,
air hoses, valves and bladders
Summe: 2490,- Euro and - ..cost for wrapping and shipping
Shipping-information:
The cost for shipping, you get it after you have sent me the order form back.
Terms of payment:
-The full amount due must be paid before delivery. Please take into consideration
that the machine must be paid for in advance.
-Please notice, the produce of your device beginning after arrival your money-transfer.
The delivery time will be 3 - 4 weeks!!!
-Please make the money-transfer only in Euro. You get all information about this by your
bank-office. Please include the name of your child with the remittance. It is very important!!
-As soon arrival your money-transfer, you get a confirmation about this and the