Diversified Services

Print and Snail Mail Order Form

Check Payment Method: $_________Amount Enclosed

________________________________________Name
________________________________________Company Name
________________________________________Type of Business
________________________________________Address
________________________________________City/State/Zip
________________________________________Country
________________________________________Day-Time Phone
________________________________________Fax
________________________________________E-mail Address

________________________________________Directory Name

________________________________________Password
Should be 6 characters or more.

Month's_______Complete Web Site $3mo
Month's_______Commercial Web Site $12mo
Qty___________Custom Design Web Pages $15 per Page
Qty___________SoftQuest Office Ver 4.0 $199.00