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  1. <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 3.2//EN">
  2. <HTML>
  3.  
  4. <HEAD>
  5. <META HTTP-EQUIV="Content-Type" CONTENT="text/html; charset=windows-1252">
  6. <META NAME="Template" CONTENT="C:\MSOFFICE\OFFICE\html.dot">
  7.  
  8.     <META NAME="GENERATOR" Content="Visual Page 1.0 for Windows">
  9.     <META HTTP-EQUIV="Content-Type" CONTENT="text/html;CHARSET=iso-8859-1">
  10.     <TITLE>PICPLUCK ORDER FORM</TITLE>
  11. </HEAD>
  12.  
  13. <BODY BGCOLOR="#66FFCC" LINK="#0000FF" VLINK="#800080">
  14.  
  15. <FORM METHOD="POST" ENCTYPE="application/x-www-form-urlencoded">
  16. <P><!--CTYPE HTML PUBLIC "-//W3C//DTD HTML 3.2//EN"><--></P>
  17. <H1 ALIGN="CENTER">PicPluck</H1>
  18. <FONT SIZE="2" FACE="Courier New"> </FONT>
  19. <H4 ALIGN="CENTER">To pay by check or by fax, simply type out this form, select Print from your browser's menu,
  20. SIGN AND DATE if you are paying by credit card, then fax or mail the printout and your payment to the fax/address
  21. below.  Make checks payable to "Vaden Research, Inc."</H4>
  22. <H3 ALIGN="CENTER">Vaden Research, Inc., 14150 NE 20th St, Suite 381, BELLEVUE, WA 98007, USA</H3>
  23. <H3 ALIGN="CENTER">Fax (425) 643-7928</H3>
  24. <P ALIGN="CENTER">We will email the PicPluck unlock code to you upon receipt of cleared funds. <B>Double-check
  25. your email address before sending.  If you provide an incorrect email address, you may not receive the unlock code!</B></P>
  26.  
  27. <P ALIGN="CENTER"><B><BR>
  28. All fields must be filled in for credit-card verification and so that we may contact you if we have a question
  29. about your order.</B>. All information is confidential and is not given or sold to third parties.</P>
  30. <P>
  31. <H3 ALIGN="CENTER"><FONT COLOR="#FF0000">Your card will be charged $29.95 (U.S.) by Vaden Research, Inc.</FONT></H3>
  32. <CENTER>
  33. <P>
  34. <TABLE BORDER="1" CELLSPACING="1">
  35.     <TR>
  36.         <TD WIDTH="39%" VALIGN="MIDDLE">Your Email Address:</TD>
  37.         <TD WIDTH="61%" VALIGN="MIDDLE"><INPUT TYPE="TEXT" NAME="email" SIZE="60"></TD>
  38.     </TR>
  39.     <TR>
  40.         <TD WIDTH="39%" VALIGN="MIDDLE">Your Name as it appears on credit card:</TD>
  41.         <TD WIDTH="61%" VALIGN="MIDDLE"><INPUT TYPE="TEXT" NAME="Name" SIZE="60"></TD>
  42.     </TR>
  43.     <TR>
  44.         <TD WIDTH="39%" VALIGN="MIDDLE">Country:</TD>
  45.         <TD WIDTH="61%" VALIGN="MIDDLE"><INPUT TYPE="TEXT" NAME="Country" SIZE="60"></TD>
  46.     </TR>
  47.     <TR>
  48.         <TD WIDTH="39%" VALIGN="MIDDLE">Phone Number:</TD>
  49.         <TD WIDTH="61%" VALIGN="MIDDLE"><INPUT TYPE="TEXT" NAME="75" SIZE="60"></TD>
  50.     </TR>
  51.     <TR>
  52.         <TD WIDTH="39%" VALIGN="MIDDLE">Card Type:</TD>
  53.         <TD WIDTH="61%" VALIGN="MIDDLE">            <SELECT NAME="cardtype">
  54.             <OPTION VALUE="VISA">VISA </OPTION>
  55.             <OPTION VALUE="MasterCard">MasterCard </OPTION>
  56.             <OPTION VALUE="American Express">American Express </OPTION>
  57.             <OPTION VALUE="Discover">Discover </OPTION>
  58.             </SELECT>
  59.         </TD>
  60.     </TR>
  61.     <TR>
  62.         <TD WIDTH="39%" VALIGN="MIDDLE">Card Number:</TD>
  63.         <TD WIDTH="61%" VALIGN="MIDDLE"><INPUT TYPE="TEXT" NAME="cardnumber" SIZE="60"></TD>
  64.     </TR>
  65.     <TR>
  66.         <TD WIDTH="39%" VALIGN="MIDDLE">Exp Date:</TD>
  67.         <TD WIDTH="61%" VALIGN="MIDDLE">            <SELECT NAME="Month">
  68.             <OPTION SELECTED>01 </OPTION>
  69.             <OPTION>02 </OPTION>
  70.             <OPTION>03 </OPTION>
  71.             <OPTION>04 </OPTION>
  72.             <OPTION>05 </OPTION>
  73.             <OPTION>06 </OPTION>
  74.             <OPTION>07 </OPTION>
  75.             <OPTION>08 </OPTION>
  76.             <OPTION>09 </OPTION>
  77.             <OPTION>10 </OPTION>
  78.             <OPTION>11 </OPTION>
  79.             <OPTION>12 </OPTION>
  80.             </SELECT>
  81.              <SELECT NAME="Year">
  82.             <OPTION SELECTED>1998 </OPTION>
  83.             <OPTION>1999 </OPTION>
  84.             <OPTION>2000 </OPTION>
  85.             <OPTION>2001 </OPTION>
  86.             <OPTION>2002 </OPTION>
  87.             <OPTION>2003 </OPTION>
  88.             <OPTION>2004 </OPTION>
  89.             <OPTION>2005 </OPTION>
  90.             </SELECT>
  91.         </TD>
  92.     </TR>
  93.     <TR>
  94.         <TD WIDTH="39%" VALIGN="MIDDLE">How did you find us?</TD>
  95.         <TD WIDTH="61%" VALIGN="MIDDLE"><INPUT TYPE="TEXT" NAME="Referrer" SIZE="60"></TD>
  96.     </TR>
  97.     <TR>
  98.         <TD WIDTH="39%">Your signature for credit card orders:</TD>
  99.         <TD WIDTH="61%"> </TD>
  100.     </TR>
  101. </TABLE>
  102. </P>
  103. </CENTER>
  104. <P ALIGN="CENTER"> 
  105. <P>
  106. </FORM>
  107.  
  108.  
  109. </BODY>
  110.  
  111. </HTML>