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  1.                     SciTech Display Doctor for OS/2 1.0
  2.                                 Order Form
  3.  
  4. SciTech Software, Inc.                                           __/___/___
  5. 505 Wall Street                                                  MM /DD /YY
  6. Chico, CA 95928 USA
  7. Toll free: 800-486-4823         Phone: 530-894-8400       Fax: 530-894-9069
  8.                   sales@scitechsoft.com  www.scitechsoft.com
  9.  
  10. PLEASE PRINT CLEARLY OR TYPE!
  11.  
  12. Name: _____________________________________________________________________
  13.  
  14. Company: __________________________________________________________________
  15.  
  16. Address: __________________________________________________________________
  17.  
  18. City: __________________________________  State: __________________________
  19.  
  20. Zip/Postal Code: _______________________  Country: ________________________
  21.  
  22. Phone: _________________________________  Fax: ____________________________
  23.  
  24. Email(required for orders placed via email):_______________________________
  25.  
  26. Register product(s) to: [ ] Company     [ ] Individual
  27.  
  28. Pay By:  [ ]Check*(USA only)**   [ ]Money Order(US Funds)**  [ ]Credit Card
  29.                   *$15.00 charge for all returned checks
  30.                   **Orders cannot be processed until payment is received
  31.  
  32.     Credit Card Orders: MasterCard / Visa / Amex / Discover (Circle one)
  33.  
  34.     Card Number ______________________________________   Expires ____/____
  35.  
  36.     Cardholder's name (print) ____________________________________________
  37.  
  38.                  Item                             Cost      Qty     Price
  39. -------------------------------------------     --------    ---     ------
  40. SciTech Display Doctor 1.0 w/Disks & Manual     US$39.95    ___   $ ______
  41.  
  42.      Subtotal                                                     $ ______
  43.      California residents ONLY add sales tax      7.25%           $ ______
  44.      Shipping & Handling Charges              US: $9.95                        
  45.                                             Intl: $14.95          $ ______
  46.  
  47.      Total Enclosed                                               $ ______
  48.  
  49.   I have read and agree to abide by the enclosed license agreement and I 
  50.   agree to be bound by my credit card agreement. If shipping charges have 
  51.   changed, I agree to pay the new charge.
  52.  
  53.       (Signature required) _____________________________________
  54.            Shipping charges are subject to change without notice
  55.