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  1. If possible, please fill out the following form, print, and fax it to DataStream Imaging
  2. Systems, Inc. If this is a problem, please contact us and we will make further arrangements.
  3.  
  4.                                                 WildRiverSSK Order Form
  5.  
  6. PLEASE FAX THIS COMPLETED ORDER FORM to 606-259-1541
  7.  
  8.  
  9. Please Complete The Entire Form
  10.  
  11.      Name:_______________________
  12.    E-mail:_______________________
  13. Company:_______________________
  14.  Address:_______________________
  15.               _______________________
  16.  
  17.       City:_______________________
  18.     State:_______________________
  19. Postal Code:____________________
  20.     Phone:______   _______   _______
  21.  
  22. ----------------------------------------------------------------------------
  23. Shipping:
  24. FedEx Account:
  25. ----------------------------------------------------------------------------
  26.                  Payment:
  27.        Company Check:
  28.                         COD:
  29.               Circle One:
  30. VISA/MC/DISCOVER
  31.  
  32. Credit Card Number:_____________________________
  33.     Expires (MM/DD) :
  34.  
  35.  
  36.  
  37.                              ORDER INFORMATION
  38.                 PRODUCT      QUANTITY        UNIT PRICE SUBTOTAL
  39.  
  40.               WildRiverSSK  _______        $99.95 ea. ________
  41.  
  42.                                                         SHIPPING &  ________
  43.                                                           HANDLING
  44.                                                         
  45.                                                        
  46.                                              
  47.                                                    (KY residents,
  48.                                                   please add 6%)
  49.                                                          SALES TAX   ________
  50.  
  51.                                                                 TOTAL   ________
  52.  
  53. ----------------------------------------------------------------------------                        
  54.             We welcome comments/suggestions regarding our site.
  55.        You may contact us via: info@datastrem.com or ftp.datastrem.com
  56.                              
  57.  Street Address:  585 West Main St.
  58.                            Lexington, KY
  59.                            40507
  60.  
  61.  Mailing Address: P.O. Box 2148
  62.                            Lexington, KY 
  63.                            40595
  64.  
  65. Telephone #:  (606)255-6686
  66.                 
  67.                              Information By Fax:
  68. Available 24 hours a day, 7 days a week. Call 606-252-2676 or 1-800-889-7781
  69. from a touch-tone phone to request information on our products and services.                              
  70.  
  71. PLEASE FAX THIS COMPLETED ORDER FORM to 606-259-1541