PLEASE VIEW THE SOURCE OF THIS ORDER FORM

(Your Company Name) Order Form

Please complete the following form to place your order. We will calculate the form and confirm your order by email.

T-Shirt ($10.99 each): Quantity: Color: Size:
Software Package ($110.00 each): Quantity:
28.8 Modem ($95.99 each): Quantity:

Select the items you wish to order:
Chocolate Malt ($2.95)
Strawberry Malt ($2.75)
Vanilla Malt ($2.85)

One Month Subscription
$19.95
Three Month Subscription
$35.95
Six Month Subscription
$49.95
One Year Subscription
$59.95

General Information
(As Shown On Your Credit Card Statement. Your Address Will Be Verified.)
First Name: Last Name:
Address:
City: State: Zip:
Country:
Phone Number:
E-Mail Address:
Credit Card Information
Card Number: Exp. Date:

If you would like, you may specify an alternate shipping address. Enter that information here.
First Name: Last Name:
Address:
City: State: Zip:
Country:

Submit this form ONCE ONLY.
Your credit card information will be processed in real-time. You should receive a response in about 15-25 seconds. However, if Internet traffic is unusually high, the tranaction could take longer than usual. Pressing the submit button multiple times will cause multiple charges to your credit card account.