LAN-Projekt
       Placheho 17     tel: +420 19 722 43 05
301 26 PLZEN           fax: +420 19 722 43 10
       Czech Republic
       Europe

WinProxy Upgrade - Order Form
=============================

Your present serial number:__________________________

Your present key:____________________________________

Select type of your upgrade:

[ ] from 5 to 10-user    (120 USD)
[ ] from 5 to unlimited  (240 USD)    
[ ] from 10 to unlimited (120 USD)    


Select option of payment for WinProxy:

[ ] Credit Card - we can accept VISA or Eurocard / MasterCard only
[ ] Bank Transfer to our account "CSOB - CEKO CZ PP PLZ 4405000"
     (a transfer fee is paid by sender)
[ ] Cheque (attach it to this form and send it by post, please)

Concerning my person / company

 Name: ______________________________________ 

 Company: ___________________________________

 Address: ___________________________________

 City: ______________________________________

 Country: ___________________________________

 Post Code: _________________________________

 Telephone: _________________________________

 Fax: _______________________________________

 E-mail: ____________________________________


In case of payment by credit card please fill in the following:

 Card type:     
  (Other cards are not supported)  

  [ ] Visa Eurocard
  [ ] MasterCard


 Card number: _______________________________

 Card Validation Code 2 (CVC2): __________________________________  [EC/MC]

 Card Verification Value 2 (CVV2): _______________________________  [VISA]

 Card holder: _______________________________

 Valid until: _______________________________


I promise I won't use my old serial number after upgrading.

Date:__/__/__     Signed:____________________ (required)


Please fill in the form clearly, legibly and in English.

Additional comments: