\documentclass[12pt]{article}
\usepackage{a4,latin1,babel,italian}

\selectlanguage{italian}

\parindent 0mm

\begin{document}
\pagestyle{empty}
\frenchspacing
\vspace{-1cm}
\begin{tabular}{l c r}
{\large MODULO 2} & \makebox[6cm]{ } & {\large from Italy} \\
\end{tabular}

\vspace{.8cm}

{\LARGE {\bf DICE 3.02 Order Form}}

\rule[.4cm]{8.5cm}{1pt}

\vspace{.1cm}

\begin{tabular}{r l}
Surname: & \makebox[7cm]{ \dotfill } \\
Name: & \makebox[7cm]{ \dotfill } \\
Company: & \makebox[7cm]{ \dotfill } \\
Address: & \makebox[7cm]{ \dotfill } \\
\end{tabular}

\begin{tabular}{r l r l}
City: & \makebox[4cm]{ \dotfill }    & ZIP: & \makebox[3cm]{ \dotfill } {\bf ITALY}\\
Telephone: & \makebox[4cm]{ \dotfill } & Internet: & \makebox[3cm]{ \dotfill } \\
Telefax: & \makebox[4cm]{ \dotfill }  &  Fido: & \makebox[3cm]{ 2: \dotfill } \\
\end{tabular}

\vspace{.5cm}

Indicate number of each product (shipping is included in this price):

\begin{tabular}{c r l }
Q.ty & Prize & Description \\
\makebox[.8cm]{ \dotfill } & \$80 & DICE 2.0x.xx user \\
\makebox[.8cm]{ \dotfill } & \$95 & SAS or MANX owner  \\
 & & Write serial number here \makebox[3cm]{ \dotfill } \\
\makebox[.8cm]{ \dotfill } & \$155 & New order \\
\end{tabular}

\vspace{5mm}

Amount: \makebox[5cm]{ \dotfill }

\vspace{3mm}

Check: \begin{tabular}{l c l} $ \bigcirc $ VISA & \makebox[1cm]{ } & $ \bigcirc $ Mastercard \\
\end{tabular}

\vspace{7mm}

Credit card number: \makebox[1.2cm]{ \dotfill } \makebox[.1cm]{ } \makebox[1.2cm]{ \dotfill } \makebox[.1cm]{ } \makebox[1.2cm]{ \dotfill } \makebox[.1cm]{ } \makebox[1.2cm]{ \dotfill }

\vspace{7mm}

Expiration Date: \makebox[2cm]{ \dotfill }

\vspace{7mm}

Signature: \makebox[7cm]{ \dotfill }

\vspace{2cm}

\begin{center}
Send full filled order to:

\sc

Obvious Implementations Corporation \\
P.O. Box 4487 	                    \\
Cary, NC 27519-4487                 \\
USA \\
FAX: 001-919-469-3853
\end{center}
\end{document}