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  1.                          UNITED KINGDOM ORDER FORM
  2.                          ~~~~~~~~~~~~~~~~~~~~~~~~~
  3.  
  4. Credit card orders only. Visa or Mastercard.
  5.  
  6. To register send payment/order to our local agent:
  7.  
  8.     ENSIGN SYSTEMS
  9.     21 Tredown Road
  10.     Sydenham
  11.     LONDON SE26 5QQ
  12.  
  13.     Credit card order Line: 0181-778-2871
  14.  
  15.     Fax order Line: 0181-778-2871
  16.  
  17.     Email:  ensignpub@aol.com
  18.  
  19.     Web site: http://www.ensignpub.com
  20.  
  21. Please provide the following information:
  22.  
  23. Name_____________________________________
  24.  
  25. Address_____________________________________________________________________
  26.  
  27. Address_____________________________________________________________________
  28.  
  29. City___________________ State/Prov.______________Zip/Postal Code____________
  30.  
  31. Country_____________________________________________________________________
  32.  
  33. E-Mail (if any)____________________
  34.  
  35. Fax (if any)_______________________  Phone (optional)_______________________
  36.  
  37.  
  38. PELLENC's Products:
  39. ~~~~~~~~~~~~~~~~~~
  40.  
  41. [ ] Bomb Golf License at ú9.99        _________
  42.  
  43. [ ] 32 Card Bridge License at ú12.95    _________
  44.  
  45. [ ] Hockey Pong License at ú9.99    _________
  46.  
  47.     + Shipping:    Code only: FREE         
  48.         Disks: ú2.00        _________
  49.  
  50.             TOTAL        _________
  51.  
  52.  
  53. Payment Method:
  54. ~~~~~~~~~~~~~~
  55.  
  56. VISA ____     MasterCard  ____ 
  57.  
  58. Name exactly as on credit card _________________________________
  59.  
  60. Credit Card #_______________________________________ Expiration Date__________
  61.  
  62.  
  63. Signature ___________________________________________
  64. (Only required for mail in and FAX credit card orders)
  65.  
  66. Thank you for registering.