Order Form

SMART PIX MANAGER ORDER FORM

Customer Details:

First Name: ____________________

Last Name:____________________

E-mail Address: ____________________

Please confirm e-mail: ____________________

Address: ____________________

____________________

City: ____________________

State/Province: ____________________

Postal Code: ____________________

Country: ____________________

Phone: ____________________   [ ]Day?  [ ]Night?

Payment method:

[ ]Credit card, [ ]Personal Cheque, [ ]Cash.

CREDIT CARD DETAILS:

[ ] Visa

[ ] Mastercard

[ ] American Express

[ ] _________________

Credit Card #:  ____________________   

Expiration Date:  __/__/__(MM/DD/YY or MM/YY)

Name on card: ____________________

PERSONAL CHECK DETAILS

Name on check: ____________________

Check number: ____________________

Currency: ____________________

Conversion rate: ____________________

Date of this rate: ____________________

CASH DETAILS

if other than US$:

Currency: ____________________

Conversion rate: ____________________

Date of this rate: ____________________

Items required:

(You can use the world currency converter at http://www.oanda.com/converter/classic to convert this into your own currency)

Order confirmation should be:

[ ]Posted

[ ]E-mailed

Other:

Where did you hear about this product?

___________________________________________

What improvements would you like us to make to the program?

___________________________________________

Have you had any problems with the program?

___________________________________________