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Text File  |  1999-11-20  |  2KB  |  73 lines
  1. --------------------------------------------------------------------------------
  2.  
  3.                           Talisman Order Form
  4.  
  5. --------------------------------------------------------------------------------
  6.  
  7.  
  8.  
  9. Product nameá     Talisman
  10.  
  11. Product ID        1333-4 
  12.  
  13.   
  14. Unit Quantity:á ______
  15.  
  16. Price ($U.S.)   ______
  17.  
  18. TOTAL AMOUNT ($U.S.)á __________
  19.  
  20.  
  21.  
  22. Payment Information:
  23.  
  24.  
  25. First Name: ____________________________________________
  26.  
  27. Last Name: _____________________________________________
  28.  
  29. Company: _______________________________________________
  30.  
  31. Street Address: ________________________________________
  32.  
  33. ________________________________________________________
  34.  
  35. City: áá _______________________________________________
  36.  
  37. State/Province: ________________________________________
  38.  
  39. Zip/Postal Code: _______________________________________
  40.  
  41. Country: _______________________________________________
  42.  
  43. Daytime Phone: _________________________________________ 
  44.  
  45. Fax: ___________________________________________________
  46.  
  47. Email Address: _________________________________________
  48.  
  49.  
  50. Payment:
  51.  
  52.  
  53. ___ MasterCard ___ VISA ___ AMEX ___ Discover
  54.  
  55. ___ Check ___ Money order
  56.  
  57.  
  58. For credit card orders:
  59.  
  60.  
  61. Name on Card: __________________________________________
  62.  
  63. Credit Card Number: ____________________________________
  64.  
  65. Expiration Date: 
  66. month ________________ year (4 digits) _________________
  67.  
  68. á
  69.  
  70.  
  71. Signature : ____________________ Date: _________________
  72.  
  73.