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Text File  |  2001-05-14  |  1.8 KB  |  52 lines
  1. Order Information
  2. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
  3.  
  4. Outbreak (3010-11)                        Price/Unit  Quantity  Total
  5. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
  6.                                            $18.95     ________  _____
  7.  
  8. TOTAL AMOUNT ($U.S.)                           __________
  9.  
  10. Payment Information
  11. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
  12.  
  13. First Name:    _____________________________________________________
  14.  
  15. Last Name:    _____________________________________________________
  16.  
  17. Company:    _____________________________________________________
  18.  
  19. Street Address: _____________________________________________________
  20.  
  21.                 _____________________________________________________
  22.  
  23. City:        _____________________________________________________
  24.  
  25. State/Province:  ____________________________________________________
  26.  
  27. Zip/Postal Code:   __________________________________________________
  28.  
  29. Country: ____________________________________________________________
  30.  
  31. Daytime Phone:    ___________________________________________________
  32.  
  33. Fax: ________________________________________________________________
  34.  
  35. Email Address (required): ___________________________________________
  36.  
  37. Payment:        __ MasterCard     __ VISA     __ AMEX     __ Discover
  38.  
  39.                 __ Check       __ Money order       __ Purchase order
  40.  
  41. For credit card orders
  42. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
  43.  
  44. Name on Card: _______________________________________________________
  45.  
  46. Credit Card Number: _________________________________________________  
  47.  
  48. Expiration Date: month ________________ year (4 digits) _____________
  49.  
  50.                 Signature : ___________________  Date: ______________
  51.  
  52.