EmailMe Form - VAT Exemption Form

Name of Purchaser
(if you are buying for someone else).
First Last
Date of birth of person eligible for VAT Relief.
MM / DD / YYYY
Name of the person eligible for VAT Relief. *
First Last
Please enter the address of the person eligible for VAT Relief. *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Contact phone number purchaser *
Email address of purchaser
Please state illness (or charity number) qualifying you for VAT Relief *
Date of purchase *
MM / DD / YYYY
I am receiving the goods from kiwik.co.uk and they are being supplied for domestic or personal use. Please fill in your name to sign this as a true statement. *