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Text File  |  2003-02-21  |  2KB  |  58 lines
  1.           Audio Caller ID Registration Form
  2.  
  3. Name:     ______________________________________
  4.  
  5. Address:  ______________________________________
  6.  
  7. City:     ________________________    State:  __
  8.  
  9. Zip Code: __________     Country: ______________
  10.  
  11. E-mail address: ________________________________
  12.  
  13. How did you obtain Audio Caller ID?
  14. ________________________________________________
  15.  
  16. Any improvements that you would like to see?
  17. ________________________________________________
  18. ________________________________________________
  19.  
  20. ************************************************
  21. Registration Fee: (choose any that apply)
  22.  
  23.     New Registration          $19.95        ____
  24.  
  25.  
  26. Program on CD: (Optional)                 + ____
  27.   Within United States           $10
  28.   Outside United States          $15
  29.  
  30. Total Payment Enclosed:                   = ____
  31.  
  32. If paying by check, please make it payable to
  33. "Beiley Software Inc.".  US funds only please.
  34. ************************************************
  35.  
  36. Please send payment to:
  37.  
  38.   Beiley Software Inc.
  39.   P.O. Box 51641
  40.   Phoenix, AZ 85076-1641
  41.  
  42.   E-mail:  audiocallerid@beiley.com
  43.   Phone:   (480) 705-0129
  44.   FAX:     (480) 705-9219
  45.  
  46. If paying by credit card please fill in the following:
  47.  
  48. Card Number:________________________________________
  49.  
  50. Circle one: Visa  MasterCard  Discover  Amex
  51.  
  52. Expiration Date (mm/yy):___/___
  53.  
  54. CVV2 (Last 3 digits on back side of card):____
  55. (Where your signature is located. Ignore if not available.)
  56.  
  57. Cardholder's Signature:______________________________
  58.