ORDER FORM -- for phone, fax, and e-mail orders
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Your Name:
Billing Address (the address your credit card bill is sent to)
Street:
City:
State:
Zipcode:
Country:
Mailing Address (if different than billing address)
Street:
City:
State:
Zipcode:
Country:
Home Phone Number:
Work Phone Number:
E-mail Address:
Credit Card Information
Type (Visa, Mastercard, American Express, Discover)
Account Number:
Expiration Date:
Software to Order
Title: Capture By George!
Reg.Net ID: 10978
Quantity:
Shipping Option: registration key delivery by e-mail
Shipping Cost: 0.00
Total Dollar Amount:
If FAXed or e-mailed, please include the following language (and sign
if FAXed):
I authorize Reg.Net(TM) to bill my credit card and agree to pay
the total amount according to card issuer agreement.
_________________________ _____________
Signature Date
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