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.

User Name:                 passphrase:

Check Number:               Check Memo:

(Both of these fields are optional.)
Please enter the quantity only for the item(s) you would like to order below. The unit price for each item is shown in parenthesis. Click on the product name to read the catalog description. We will calculate the form and confirm your order by e-mail.

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
First Name: Last Name:
Address:
City: State: Zip:
Country:
Phone Number:
E-Mail Address:
OPTION 1:
PAY WITH A CREDIT CARD
Card Number: Exp. Date:

OPTION 2:
PAY WITH A CHECK
At the bottom of your check is a series of numbers, separated by symbols. It is not necessary to enter symbols or spaces in the fields provided below.

Enter the series of nine numbers
between this symbol
Enter the series of numbers
found before this symbol
Check number to use:
Note: Some banks use a non-standard format in this series of numbers. If your account number includes this symbol , simply disregard the symbols and enter this section of numbers.
Submit this form ONCE ONLY.
Your payment information will be processed in real-time. You should receive a response in about 10-25 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 account.