Purchasing Contact Information: Name __________________ Email __________________ School __________________ Student ID __________________ Professor's Email __________________ Address 1 __________________ Address 2 __________________ City __________________ Prov/State __________________ Zip/Postal __________________ Country __________________ Telephone __________________ Fax __________________

Purchase Information: Product name ActiveState Perl Debugger Indicate whether you would like a Machine License or a User License and fill in either the Machine or User name.   M[ ] U[ ] Name __________________

Billing Contact Information:
Enter your credit card information exactly as it appears on your credit card and/or billing statement.

Name	____________________________________
Street Address	____________________________________
City	____________________________________
Prov/State	____________________________________
Zip/Postal	____________________________________
Country	____________________________________
Credit Card (Please circle one):   Mastercard   Visa   JCB
Card Number	____________________________________
Expiration Date (mm/yy)	____________________________________

*Choosing a license: A User Name license allows you to install on multiple machines, however, you must log on with the same User Name. A Machine Name license allows you to install on one machine, however, you may log on with any User Name.
Determining your User Name: Your user name is the name you enter when you logon to your computer. If you are using Windows 95 and do not logon to your computer at startup, please use the user name you enter when you log on to your network or connect to your Internet Provider.
Determining your Machine Name: On both Windows NT and Windows 95, open the Network control panel, and select the Identification tab. You will find your Machine Name in the Computer Name text field.