regform.txt

游戏 坦克 游戏 坦克 游戏 坦克

Battlejeep ordering form
------------------------

If you do not have access to the Internet, you can register via
phone, fax or postal mail. Please print out the following form,
and fax or mail it to:

 Register Now!
 Dept# 2564-7
 PO Box 1816
 Issaquah, WA 98027
 United States of America 

 Phone:
      Toll Free: 877-353-7297
      Regular:   425-392-2294
 Fax:
      Toll Free: 888-353-7276
      Regular:   425-392-0223

Personal Information

  Program No.: 2564-7

  First Name:      ___________________________________________

  Last Name:       ___________________________________________

  Company:         ___________________________________________

  Street Address:  ___________________________________________

  City:            ___________________________________________

  State/Province:  ___________________________________________

  Zip/Postal Code: ___________________________________________

  Country:         ___________________________________________

  Phone:           ___________________________________________

  Email Address:   ___________________________________________
 
Order Information  

  Quantity: ______

  Price:  $15
 
Payment Information  

  Name on Card: _____________________________

  Type of Credit Card: ______________________

  Card Number: ___________________

  Expiration Date:  Month ________ Year(4 digits) _______