LAN-Projekt
       Placheho 17     tel: +420 19 722 43 05
301 26 PLZEN           fax: +420 19 722 43 10
       Czech Republic


WinProxy Order Form
===================

[ ] WinProxy 5-user    (99 USD)            quantity:______
[ ] WinProxy 10-user   (199 USD)           quantity:______
[ ] WinProxy unlimited (299 USD)           quantity:______

                                          Total USD:______

Select option of payment for WinProxy:

[ ] Credit Card - we can accept VISA or Eurocard / MasterCard only
[ ] Bank Transfer to our account "CSOB - CEKO CZ PP PLZ 278871003"
     (transfer fee is paid by sender)
[ ] Cheque (attach it to this form and send it by post, please)


Concerning my person / company

 Name: ______________________________________ 

 Company: ___________________________________

 Address: ___________________________________

 City: ______________________________________

 Country: ___________________________________

 Post Code: _________________________________

 Telephone: _________________________________

 Fax: _______________________________________

 E-mail: ____________________________________


In case of payment by credit card please fill in the following:

 Card type (other cards are not supported):

  [ ] Visa Eurocard            [ ] MasterCard

 Card number: _______________________________

 CVC2 / CVV2: __________________________________  
 (The last three-digit No. on the back side of your card)


 Card holder: _______________________________

 Valid until: _______________________________



Do you want to receive trial key before the order is processed?

 [ ] 20 day tial key


Date:__/__/__     Signed:____________________
                   (required)

Additional comments: