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Text File  |  2000-06-01  |  1.2 KB  |  62 lines
  1. ORDER FORM
  2.  
  3. Text2Web Pro (RegSoft Product ID: 6387 
  4.  
  5. Last name: ___________________________________
  6.  
  7. First name: ____________________________________
  8.  
  9. Street and #: ______________________________________
  10.  
  11. Locality: ________________________________
  12.  
  13. Town/City: ________________________________
  14.  
  15. State/County, postal/ZIP code: ________________________________
  16.  
  17. Country: _______________________________________
  18.  
  19. Phone: _____________________________________
  20.  
  21. Fax: ________________________________________
  22.  
  23. E-Mail: ______________________________________
  24.  
  25.  
  26. How would you like to receive the password (e-mail, fax or 
  27. postal mail)?
  28.  
  29. ___________________________________
  30.  
  31.  
  32. Upgrade fee: 
  33.  
  34.     Single User licence             : US   $25.00   [ ]
  35.     
  36.     How many? ____________    Total Amount: ______________
  37.     
  38.  
  39. Method of payment: ___________________________________
  40.  
  41.  
  42. Credit card information (if applicable)
  43.  
  44. Credit card: ________________________________
  45.  
  46. Card No.: ___________________________________
  47.  
  48. Card holder: ________________________________
  49.  
  50. Date of Expiry : ___________________________________
  51.  
  52.  
  53.  
  54. Signature ___________________________
  55.  
  56.  
  57. Date ___________________________
  58.  
  59.  
  60.  
  61.  
  62.