| CLAIM | ||
| title: | ISSN: | |
| missing issue: | ||
| month: | year: | issue: | 
| TYPE OF SUBSCRIPTION | ||
| yearly | semi-yearly | |
| started: | finished: | |
| back issues | ||
| volume: | issue: | month: | year: | 
| CUSTOMER’S DETAILS | ||
| individual: | ||
| personal name: | family name: | |
| company: | ||
| name: | ||
| institution: | ||
| name: | ||
|  | ||
| phone: | fax: | |
| e-mail: | ||
| COMMENTS | ||