| CyberView Image ver. 4.5.4 ORDER FORM | |||
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| Electronic delivery of Copies:__________x $29.95 = .......... | _____________ | ||
| Georgia residents add your local sales tax:____% = .......... | _____________ | ||
| Continental US destinations only: | |||
| Program diskette shipped by US Postal Service add $3.00 .. | _____________ | ||
| Total payment ......................... | _____________ | ||
| If you chose electronic delivery only, your e-mail address is required. | |||
| Please Print (or write capitals) | |||
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Name: | ________________________________________________ |
| Company: | ________________________________________________ | |
| Address: | ________________________________________________ | |
| City: | ___________________________Zip:__________________ | |
| State: | ________________________________________________ | |
| Country | ________________________________________________ | |
| Phone | ______________________Fax:______________________ | |
| e-mail: | ________________________________________________ |
| Card: [ ] Visa [ ] Master Card [ ] Discover [ ] American Express |
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Card Number: | ___________________________________________ |
| Expiration Date: | ___________________________________________ | |
| Card Issued To: | ___________________________________________ | |
| Zip (or postal code) | ___________________________________________ | |
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Check enclosed. Date: _________________ Signature:__________________________ Completed form fax
to: 770 - 682 - 6504 |
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