SWREG Fax Order Form
Video to Flash
Encoder
|
SWREG Product
code |
| Personal License
|
32144WSVTF01 |
| Business License
|
32144WSVTF01 |
|
|
Ship-To Name &
Address:
|
| Company
name: |
| Address: |
| Phone
+ Fax: |
| Your
email address - in capitals: |
| Card
number (MC, Visa, Amex, Discover, Switch, Delta, Eurocard,
Diner's): |
Expires-
Month:
Year:
Start Date
(Diners only):
Issue Number
(Switch only): |
|
|
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.)
| Name on card: |
Company name: |
Address:
(if different from above)
|
|
|
Order Details
| Item |
Price |
Quantity |
Subtotal |
| Video to Flash Encoder Personal LicenseDownload/Keycode
by email (xxxxxxxx) |
$S
49.95 |
|
|
| Video to Flash Encoder Business LicenseDownload/Keycode
by email (xxxxxxxx) |
$S
99.95 |
|
|
| Fax handling fee: |
$S
3.00 |
1 |
$S 3.00 |
| Shipping and handling: |
$S
0.00 |
0 |
$S 0.00 |
Total Order Amount in US Dollars
|
$S |
|
Card holder will pay card issuer
above amount pursuant to cardholder agreement.
|
| |
Signature:
__________________________________ |
We accept most cards including Discover, JCB, Eurocard, Diner's
Club, Delta, Switch, Visa, Amex, Mastercard but we charge a
4% surcharge on Diner's Club . |
|
|