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LAB PUTTY ORMALAB 95 LAB PUTTY ORMALAB 85 LAB PUTTY ORMALAB 75 LAB PUTTY INTERLABOSIL INTERDENT LAB PUTTY ACTIVATOR COLTENE 40ml KOREAN BEARINGS KNOCK DOWN WHEEL WHITE KEYSTONE Knock Down Wheel Rubber Acrylic Baseplate KNOCK DOWN WHEEL GREEN FOR GRINDING PORCELAIN 1pcs KINGSLEY SCRAPER DDL
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I hereby confirm that all the information provided above is true and correct. I undertake to notify Deon de Lange Dental Supplies/Lab in writing of any changes to the information supplied within 14 (fourteen) days of such changes. I accept full responsibility for the account and acknowledge that, should payment not be made within the agreed payment terms, my details may be listed with the ITC as a defaulting debtor. Furthermore, I understand and agree that in the event of non-compliance with the above undertaking, I will be held liable for all outstanding amounts, as well as any and all legal costs incurred in the recovery thereof, including but not limited to attorney-and-client fees, collection commission, and tracing costs.
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