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  1.  
  2.                            Infinitris v1.0 Order Form
  3.                            ──────────────────────────
  4.  
  5. -----------------------------------Cut Here----------------------------------
  6.  
  7. Name________________________ 
  8.  
  9. Street Address_______________________________________
  10.  
  11. City______________________  State____  Zip Code_______
  12.  
  13. Country______________________________________________
  14.  
  15. Phone  (____)_____________  Fax: (____)_____________  
  16.  
  17. InterNet E-Mail (if available) ______________________________________
  18.  
  19.  
  20. Please specify media size: [ ] 720KB  3 1/2 
  21.                            [ ] 1.44MB 3 1/2 
  22.                            [ ] 1.2MB  5 1/4
  23.  
  24. Qty  Product Name                            Price 
  25. ---  ------------                            -----
  26. ___  Infinitris v 1.0 @ $15          =       _____
  27.        
  28.      Shipping and Handling $3 =              _____
  29.      
  30.                         Sub-Total  =         _____
  31.       
  32.  
  33.       Residents of NY State add 
  34.       8.25% sales tax              =         _____
  35.  
  36.       Total                        =         _____
  37.  
  38. -----------------------------------Cut Here----------------------------------                                         
  39.  
  40.                 Make checks or money orders payable to:
  41.  
  42.                                 Leizer Portnoy 
  43.                            2940 Ocean Ave. Apt #A6
  44.                              Brooklyn, NY  11235
  45.                                      USA
  46.  
  47.                          Thank you for registering!
  48.