Credit Card order form for Spheres of Chaos for win 95 registration code.
PsL Item number is #30676

Fill in the [   ]'s, and email to
 30676@pslweb.com

Or fax to
 US 713-524-6398.
 (US number - add prefix if needed)



Ship-To Name & Address:
-----------------------

IF A FIELD DOES NOT APPLY, PLEASE LEAVE IT COMPLETELY BLANK.

(Please do not use any umlauts or characters
 with accents or diacritical marks.)

First/Middle Name  [                                                     ]
Last Name          [                                                     ]
Company name       [                                  ] --Leave blank if not a Company order.
Address line 1     [                                                     ]
Address line 2     [                                                     ]
City               [                                  ]
State/Province     [                                  ] --U.S. & Canada only.
Zip, Country       [        ], [     ]
Phone # (voice)    [                 ]
Your email address [                                  ] -- Must fill this in.

Credit card number  (MC, Visa, Amex, Discover)
                   [                                                     ]
Expiration- Month: [           ]   Year: [           ] 

Enter the BANK's name and phone number from the back of the card or from your statement.
For AMEX, just enter 'AMEX' in the blank. All others MUST have bank's name & phone.
Bank's name & phone [                                                     ]



Credit Card Holder's Name & Address:
------------------------------------

Do NOT enter the BANK's name or address in the fields below.
Enter the address where the cardholder receives the statements.
(Only fill out the spaces below if the credit card holder's name or address
is DIFFERENT from the Ship-To name and address entered in the spaces above.)

NOTICE: Address verification is done on every charge.
If the credit card billing name & address do not match either 
the address above or below, THE ORDER WILL NOT BE PROCESSED.
The best place to get the billing address is from the monthly statement.


Name on the card   [                                                     ]
Company name       [                                                     ]
Address line 1     [                                                     ]
Address line 2     [                                                     ]
City               [                                                     ]
State/Province     [                                  ]--U.S. & Canada only.
Zip, Country       [        ], [    ]   



Quantity
--------

Number of registration codes for Spheres of Chaos @ $15 each:        [    ]


You registration code will be delivered via email, so you MUST provide
a valid email address.


Bonus Offer
-----------

PsL Monthly CD-ROM:

As a bonus for ordering Spheres of Chaos you can get
the latest edition of PsL's Monthly Shareware CD-ROM
(regular price: $29.95 plus s&h) for just $10 including s&h.
(Overseas orders: shipping is $4 more.)

Send me the PsL CD-ROM.   [         ]
(type something in []'s to say yes). 
(NOTE: 1 CD only, not a subscription.)