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Text File  |  1993-07-25  |  2KB  |  50 lines
  1.             Order Form for ANCIENTO
  2.  
  3.  
  4.    Qty   Description                    Price   Total
  5.   +----+-------------------------------+-------+-----+  
  6.   |    |  ANCIENTO                     | $15.00|     |  
  7.   +----+-------------------------------+-------+-----+  
  8.   |    |                               |       |     |
  9.   +----+-------------------------------+-------+-----+
  10.   |    |                               |       |     |
  11.   +----+-------------------------------+-------+-----+
  12.                      TOTAL |     |
  13.                            +-----+
  14.  
  15.   Make checks payable to: Gabor G. Laufer M.D.   
  16.  
  17.   Disk Size:  ___ 5.25"  ___ 3.5" 
  18.   
  19.   Payment:  _____ Check (U.S. funds only)   ______ VISA   ______ MasterCard
  20.     (Note: VISA/MASTERCARD Orders are Billed as: CyberScape BBS)
  21.  
  22.   Card Number:  _______ _______ _______ _______  Expiration Date:  ________
  23.   
  24.   Signature:  ________________________  (credit card orders must be signed)
  25.   
  26.   Name:  __________________________________________________________________
  27.   
  28.   Address:  _______________________________________________________________
  29.   
  30.   City/State/Zip:  ________________________________________________________
  31.  
  32.  
  33.           Send to:
  34.  
  35.                   Gabor G. Laufer, M.D.
  36.                   P.O. Box 1135
  37.                   Russellville, KY 42276
  38.                  
  39.              Credit Card Orders Must be sent to:
  40.                   
  41.                   CyberScape BBS                                                                          
  42.                   108 Shirley Road
  43.                   Lancaster, MA 01523
  44.                   
  45.       Or Call the BBS and Order On-Line with your Credit Card:
  46.                   
  47.           CyberScape (508) 368-8456 v.32/v.42/HST
  48.                     
  49.   ------------------------------------------------------------------------
  50.