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order.frm
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1995-06-30
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2KB
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61 lines
MILLENNIUM MEDIA GROUP
ORDER FORM
Name (Please Print) ________________________________________________________
Address ____________________________________________________________________
City __________________________________ State __________ ZIP _______________
Daytime Phone Number (_______)______________________
[ ] H.U.R.L. DOS CD-ROM $39.95
SHIPPING: 5.00
PA State Sales Tax: $____________
(PA residents must include 7% sales tax)
Amount enclosed: $____________
Mail or fax this form to:
Millennium Media Group
234 N. Columbus Blvd.
Philadelphia, PA 19106
Fax #: (215) 625-2567
Or call 1-800-U-WANT-IT (1-800-892-6848), for orders only.
Type of payment: [ ] Check [ ] Visa [ ] MasterCard
Card number: _________________________
Expiration date: _____/_____
Signature: ________________________________________
Where did you get this H.U.R.L. Shareware Edition from?
Downloaded from:
[ ] Apogee BBS
[ ] ExecPC BBS
[ ] Other BBS: Name: ________________________________________________
[ ] Compuserve (CIS): Forum Name: ___________________________________
[ ] America Online (AOL)
[ ] Prodigy
[ ] Genie: RoundTable (RT) Name: ___________________________________
[ ] Delphi: Special Interest Group (SIG) Name: ______________________
[ ] Internet FTP Site: Site Name: ___________________________________
Purchased from:
[ ] Catalog Vendor: Vendor Name: ____________________________________
[ ] Retail (Store, flea market, computer fair):
Vendor Name: ______________________________
[ ] Ordered it from MILLENNIUM directly
Other:
[ ] A friend gave it to me
[ ] Where: __________________________________________________________
[ ] I don't remember