This is not a secure form. For your protection please print out the form and fax to 00 27 11 469 3199
If you do not receive a response within 48 hours please e-mail us. (gullwing@iafrica.com)
Please use a black pen only for legibility reasons


(last 3 digits on reverse of card):
Name and Address:
Specify the model, approx year and make of your car required:
Methods of payment:
Credit card: Internet transfer: Moneygram:
Place your order now by fax:
Fax to: 00 27 11 469 3199; Phone: 00 27 11 469 3198; Galleria Interior Lifestyle; P O Box 784935 Sandton Johannesburg South Africa 2146