| To: | BMT Micro Orders |
| Fax: | +1 (910) 792 1889 |
| Order Product: | 3D Flash Animator |
| Number of Licenses: | _________ |
|
Type of License: Tick one of these options |
____ Standard ____ Educational (conditions apply) |
|
Referral Number: (if available) |
_______________________ |
| Customer Name: | _______________________________________________ |
|
Email address: (required) |
_______________________________________________ |
|
Company Name: (optional) |
_______________________________________________ |
|
Street Address: (optional) |
_______________________________________________ _______________________________________________ |
|
City or Town: (optional) |
_______________________ |
|
State or Region: (optional) |
_______________________ |
|
Country: |
_______________________ |
|
Phone Numbers: (optional) |
Work: ________________ Evening: ________________ |
| Credit Card Details | |
|
Type of Card: Check one of these options |
___ VISA
___ MasterCard
___ AmericanExpress ___ NOVUS/Discover ___ Diners Club International |
| Credit Card Number: | ________________________________________ |
| Expiration Date: | Month: ____________ Year: ____________ |
|
Amount: (pricing) |
$ ____________ . ___ U.S. Dollars |
| Cardholder's Name: | _______________________________________________ |
| Cardholder's Signature: |
_______________________________________________ |