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Text File  |  2003-10-09  |  1KB  |  45 lines
  1. Lode Doomer ordering form
  2. -------------------------
  3.  
  4. If you do not have access to the Internet, you can register via
  5. phone, fax or postal mail. Please print out the following form,
  6. and fax or mail it to:
  7.  
  8.  Register Now!
  9.  Dept# 8458-1
  10.  PO Box 1816
  11.  Issaquah, WA 98027
  12.  United States of America 
  13.  
  14.  Phone:
  15.       Toll Free: 877-353-7297
  16.       Regular:   425-392-2294
  17.  Fax:
  18.       Toll Free: 888-353-7276
  19.       Regular:   425-392-0223
  20.  
  21.  
  22. Personal Information
  23.   Program No.: 8458-1
  24.   First Name:      ___________________________________________
  25.   Last Name:       ___________________________________________
  26.   Company:         ___________________________________________
  27.   Street Address:  ___________________________________________
  28.   City:            ___________________________________________
  29.   State/Province:  ___________________________________________
  30.   Zip/Postal Code: ___________________________________________
  31.   Country:         ___________________________________________
  32.   Phone:           ___________________________________________
  33.   Email Address:   ___________________________________________
  34.  
  35. Order Information  
  36.   Quantity: ______
  37.   Price:  $15
  38.  
  39. Payment Information  
  40.   Name on Card: _____________________________
  41.   Type of Credit Card: ______________________
  42.   Card Number: ___________________
  43.   Expiration Date:  Month ________ Year(4 digits) _______
  44.  
  45.