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
First Name: Last Name:
Address:
City: State: Zip:
Country:
Phone Number:
E-Mail Address:
Checking Account Information
 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.

Please submit this form only once. Pressing the submit button multiple times will cause duplicate orders and charges to your checking account.