Purchasing Contact Information: Name __________________ Email __________________ Company __________________ Web site __________________ Address 1 __________________ Address 2 __________________ City __________________ Prov/State __________________ Zip/Postal __________________ Country __________________ Telephone __________________ Fax __________________

Purchase Information: Product name ActiveState Perl Debugger For each copy you would like to purchase, indicate whether you would like a Machine License or a User License and fill in either the Machine or User name.*   M[ ] U[ ] Name __________________ M[ ] U[ ] Name __________________ M[ ] U[ ] Name __________________ M[ ] U[ ] Name __________________ M[ ] U[ ] Name __________________ M[ ] U[ ] Name __________________ M[ ] U[ ] Name __________________ M[ ] U[ ] Name __________________ M[ ] U[ ] Name __________________ M[ ] U[ ] Name __________________

Billing Contact Information:
Enter the following information or attach a purchase order form to this fax.

Accounting Contact Name	____________________________________
Accounting Contact Phone	____________________________________
Billing Address	____________________________________
PO # Number	____________________________________

*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.