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form.txt
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1999-03-07
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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: