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Fax Order Form for Health-Minder
(SWREG # 93377274635
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To order by fax using a credit card, please print out
this document, complete it and fax to Soft Shop.
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North America:
(888) 761-8826 toll free or
else (978) 336-0331
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UK:
0870 0888962
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Germany:
0441-8009935864
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Netherlands:
0208 845094
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Elsewhere:
+44 870 0888962
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Ship-To Name & Address:
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First/Middle Name:
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Last Name:
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Company name:
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Address:
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Phone + Fax
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Your email address:
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Card number (MC, Visa, Amex, Discover, Switch, Delta,
Eurocard, Diner's):
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Expires- Month: Year::
Start Date (Diners only):
Issue Number (Switch only):
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Credit Card Holder's Name & Address for
verification: Do NOT enter the BANK's name or address in the fields
below. Enter the address where the cardholder receives the
statements. (Only fill out the spaces below if the credit card
holder's name or address is DIFFERENT from the Ship-To name and
address entered in the spaces above.)
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Name on the card:
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Company name:
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Address:
(if different from above)
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Order Details
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Item
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Price
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Quantity
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Subtotal
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Health-Minder Software, electronic download
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$US 35.00
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Health-Minder Software on diskettes, US only
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$US 40.00
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Health-Minder Software on diskettes, other than US
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$US 47.50
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Health-Minder Software on CD-ROM, shipped from England.
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$US 45.00
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Fax handling fee:
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$3
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1
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$3
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Total Order Amount in US Dollars
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Card holder will pay card issuer above amount pursuant
to cardholder agreement
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Signature: __________________________________
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