Customer Details:

First Name: ____________________

Last Name: ____________________

E-mail Address: ____________________

Please confirm e-mail: ____________________

Address:

____________________

____________________

City: ____________________

State/Province: ____________________

Postal Code: ____________________

Country: ____________________

Phone: ____________________   [ ]Home?  [ ]Work?

Payment method:

[ ] Credit card, [ ] Personal Check, [ ] Cash.

CREDIT CARD DETAILS:

[ ] Visa
[ ] Mastercard
[ ] American Express
[ ] Other: _________________

Credit Card #:  ____________________   

Expiration Date:  __/__/__(MM/DD/YY or MM/YY)

Name on card: ____________________

PERSONAL CHECK DETAILS

Name on check, if not your own: ____________________

Check number: ____________________

Currency: ____________________

Conversion rate: ____________________

Date of this rate: ____________________

CASH DETAILS

if other than US$:

Currency: ____________________

Conversion rate: ____________________

Date of this rate: ____________________

Items required:

DVD PixPlay,       ____ copies at US$29.50     = US$_____

(You can use the world currency converter at http://www.oanda.com/converter/classic to convert this into your own currency)

Other:

What Operating system are you using?

[ ] Win 95/98, [ ] Win NT/2000, [ ] Win ME, [ ] Win XP, [ ] Other: ____________________

Where did you hear about this product?

___________________________________________

What improvements would you like us to make to the program?

___________________________________________

Have you had any problems with the program?

___________________________________________