Your name:
____________________________________
Name on card:
__________________________________
Name of bank that issued the
card: ___________________
Note: The card billing address
must match shipping address below:
Address:
______________________________________
City: _______________________
State: _____________
Zip code: ______________ Phone:
_________________
Email address (if any):
____________________________
Home phone number:
____________________________
Optional: CD-ROM (add extra
$5.00): _________________
Credit card: __
Visa __ Master Card
__ American Expr.
Credit card number:
______________________________
Expires: ________ Signature:
______________________
* Please print very, VERY
clearly! *
Mail this order form to:
Philip P.
Kapusta P.O. Box 661 Fredericksburg, VA 22404 USA
or FAX it to:
1-540-371-3905