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Text File  |  2000-01-01  |  3KB  |  79 lines
  1. Anonymity 4 Proxy ver. 1.52 (Product ID# 15209):  order form
  2. =====================================================================
  3.  
  4. Mail this form to:    RegSoft.com, Inc.
  5.                         PMB201
  6.                         10820 Abbotts Bridge Road
  7.                         Suite 220
  8.                         Duluth, GA 30097
  9.                         USA   
  10.  
  11. Or fax it to:        770-497-9234
  12.             
  13.  
  14. Or just call:        1-877-REGSOFT (U.S. customers)
  15.             770-319-2718  (other countries)
  16.  
  17.  
  18. Check, money order or credit card order accepted
  19. ---------------------------------------------------------------------
  20. Note: for mailed orders, the checks need to be in US Dollars and made
  21. out to "Regsoft.com Inc".
  22.  
  23. A purchase order must be faxed or mailed to the address listed above
  24. with all necessary information including billing information.
  25.  
  26.  
  27. Order Information
  28. ======================================================================
  29.  
  30. Anonymity 4 Proxy (Product ID# 15209)      Price/Unit   Q-ty     Total
  31. ----------------------------------------------------------------------
  32. License for a server 
  33. and two client computers                       $35.00   ____   _______
  34.  
  35.  
  36. TOTAL AMOUNT (US Dollars)                                  _______
  37.  
  38.  
  39. Payment Information
  40. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
  41. First Name:      _____________________________________________________
  42.  
  43. Last Name:       _____________________________________________________
  44.  
  45. Company:         _____________________________________________________
  46.  
  47. Street Address:  _____________________________________________________
  48.  
  49.                  _____________________________________________________
  50.  
  51. City:          _____________________________________________________
  52.  
  53. State/Province:  _____________________________________________________
  54.  
  55. Zip/Postal Code: _____________________________________________________
  56.  
  57. Country:         _____________________________________________________
  58.  
  59. Daytime Phone:   _____________________________________________________
  60.  
  61. Fax:             _____________________________________________________
  62.  
  63. Email Address:   _____________________________________________________
  64.  
  65. Payment:         __ MasterCard     __ VISA     __ AMEX     __ Discover
  66.                  __ Check       __ Money order       __ Purchase order
  67.  
  68.  
  69. For credit card orders:
  70.  
  71. Name on Card: ________________________________________________________
  72.  
  73. Credit Card Number: __________________________________________________  
  74.  
  75. Expiration Date: month _______________ year (4 digits) _______________
  76.  
  77.  
  78.                 Signature : ____________________  Date: ______________
  79.