home *** CD-ROM | disk | FTP | other *** search
/ Chip 2005 June / ccd0605.iso / Software / Shareware / Grafica / digphys / dig_phys.exe / $INSTDIR / orderform.txt < prev    next >
Encoding:
Text File  |  2005-04-25  |  1.5 KB  |  72 lines
  1. --------------------------------------------------------------------------------
  2.  
  3.                           Digital Physiognomy Order Form
  4.  
  5. --------------------------------------------------------------------------------
  6.  
  7.  
  8.  
  9. Product nameá     Digital Physiognomy
  10.  
  11. Product ID        7266-3 
  12.   
  13. Unit Quantity:á ______
  14.  
  15. Price ($U.S.)   _17.00_____
  16.  
  17. TOTAL AMOUNT ($U.S.)á _17.00_________
  18.  
  19.  
  20.  
  21. Payment Information:
  22.  
  23.  
  24. First Name: ____________________________________________
  25.  
  26. Last Name: _____________________________________________
  27.  
  28. Company: _______________________________________________
  29.  
  30. Street Address: ________________________________________
  31.  
  32. ________________________________________________________
  33.  
  34. City: áá _______________________________________________
  35.  
  36. State/Province: ________________________________________
  37.  
  38. Zip/Postal Code: _______________________________________
  39.  
  40. Country: _______________________________________________
  41.  
  42. Daytime Phone: _________________________________________ 
  43.  
  44. Fax: ___________________________________________________
  45.  
  46. Email Address: _________________________________________
  47.  
  48.  
  49. Payment:
  50.  
  51.  
  52. ___ MasterCard ___ VISA ___ AMEX ___ Discover
  53.  
  54. ___ Check ___ Money order
  55.  
  56.  
  57. For credit card orders:
  58.  
  59.  
  60. Name on Card: __________________________________________
  61.  
  62. Credit Card Number: ____________________________________
  63.  
  64. Expiration Date: 
  65. month ________________ year (4 digits) _________________
  66.  
  67. á
  68.  
  69.  
  70. Signature : ____________________ Date: _________________
  71.  
  72.