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  1. *****************************************************************************
  2.  
  3.              XATAX Version 1.00s - Order Form
  4.  
  5. *****************************************************************************
  6.  
  7. General:
  8.  
  9.     First Name:  _______________________________________________________
  10.  
  11.     Last Name:   _______________________________________________________
  12.  
  13.     Address:     _______________________________________________________
  14.  
  15.     City:        _______________________________________________________
  16.  
  17.     State:       _______________________________________________________
  18.  
  19.     Country:     _______________________________________________________
  20.  
  21.     Zip Code:    _______________________________________________________
  22.  
  23.     Phone #:     _______________________________________________________
  24.  
  25.     Disk Size:   ____5.25" HD   ____3.5" HD
  26.  
  27. *****************************************************************************
  28.  
  29.     Quantity:    ________ X $17.00                              ________
  30.  
  31.     Sales Tax (VA residents only, please add 4.5%):             ________
  32.  
  33.     Shipping:    Quantity X $ 3.00                              ________
  34.  
  35.     Foreign Bank Transaction Fee $2.00 (if applicable)          ________
  36.  
  37.     Foreign Order Additional Shipping $1.00 (if applicable)     ________
  38.  
  39.  
  40.     Total:                                                      ________
  41.  
  42.     ( Note: Please allow 2 to 4 weeks for delivery )
  43.  
  44. *****************************************************************************
  45.  
  46.   Pixel Painters Corporation * PO Box 2847 * Merrifield * Virginia * 22116
  47.  
  48. *****************************************************************************
  49.