Your Name: _______________
Billing Address (the address your credit card bill is sent to)
Street: _______________
City: _______________
State: _____
Zipcode: __________
Country: _______________
Mailing Address (if different that billing address)
Street: _______________
City: _______________
State: _____
Zipcode: __________
Country: _______________
Home Phone Number: _______________
Work Phone Number: _______________
E-mail Address: _______________
Credit Card Information
Type (Visa, Mastercard, American Express, Discover)
Account Number: _______________
Expiration Date: _______________
Software to Order
Title: _______________
Quantity: ____
Total Dollar Amount: __________
I authorized Querks to bill my credit card and agree to pay the total
amount according to card issuer agreement.
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Signature |
Date |
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