| FAX YOUR ORDER
TO:
Elite Concepts |
|
|
| |
| DATE | __________________________ |
| Name | ____________________________________________________________ |
| Company (optional) | ____________________________________________________________ |
| Address | ____________________________________________________________ |
| City/State/Zip | ____________________________________________________________ |
| URL Licensed To | ____________________________________________________________ |
| Your Email Address | ____________________________________________________________ |
| Contact Phone | ____________________________________________________________ |
| FAX | ____________________________________________________________ |
|
CREDIT CARD INFORMATION | |
| Credit Card # | ____________________________________________________________ |
| Exp. Date | ____________________________________________________________ |
| Name on Card | ____________________________________________________________ |
| Zip Code of credit card BILLING address |
|
| PAYMENT METHOD | |||||||
|
[ ] |
Visa |
[ ] |
MC |
[ ] |
Amex |
[ ] |
Check/MO |
LICENSE TO ORDER | ||||
| Check one | [ ] | USD$99.00- 1 Domain License | [ ] | USD$15,000.00 - Source Code License |
Signature:
X__________________________________________
I hereby authorize Elite
Concepts to charge my credit card for the amount circled above. I understand
that my order will be processed within 48 business hours.