Order Form
MAILLIST KING ORDER FORM
Customer Details
| First Name: | _____________________________________ |
| Last Name: | _____________________________________ |
| E-mail Address: | _____________________________________ |
| Confirm your e-mail | _____________________________________ |
| (or an alternative e-mail) | |
| Street: | _____________________________________ |
| Suburb: | _____________________________________ |
| City: | _____________________________________ |
| State/Province: | _____________________________________ |
| ZIP/Postal Code: | _____________________________________ |
| Country: | _____________________________________ |
| Phone: | _____________________________________ |
Payment Method
CREDIT CARD
| [
] Visa [ ] Mastercard/Eurocard [ ] American Express [ ] Discover/Novus [ ] Diners Club/Carte Blanche [ ] Other: ____________________ |
|
| Credit Card Number: | ____________________________ |
| Expiration Date: | __/__ (MM/YY) |
| Name on card: | ____________________________ |
CHECK
| Name on check: | ____________________________ |
| Check number: | ____________________________ |
| Currency (if not US$): | ____________________________ |
| Conversion rate (if not US$): | ____________________________ |
| Date of this rate (if not US$): | ____________________________ |
Order Items
| MailList King - Personal Edition, ____ copies at US$99.50 | US$_________ |
| MailList King - Business Edition, ____ copies at US$199.50 | US$_________ |
| MailList King - Corporate Edition, ____ copies at US$899.50 | US$_________ |
| Total | US$_________ |
(You can use the world currency converter at www.oanda.com/converter/classic to convert this into your own currency)
See also: