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*   CHTsoft TrayClip Fax/Mail Order Form   *
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ORDER INFORMATION

    Product Name: TrayClip

      Product ID: 1397-1

        Quantity: ______

           Price: $10,00 each / $2,50 once for order



PERSONAL INFORMATION

      First Name: __________________________________

       Last Name: __________________________________

         Company: __________________________________

 Billing Address: __________________________________

                  __________________________________

            City: __________________________________

  State/Province: __________________________________

 Zip/Postal Code: __________________________________

         Country: __________________________________

           Phone: __________________________________

   Email Address: __________________________________
                         (if you have one)



PAYMENT INFORMATION

    Name on Card: __________________________________

    Type of Card:  O Visa
                   O American Express
                   O Discover (Novus)
                   O Mastercard
                   O Eurocard

     Card Number: __________________________________

 Expiration Date: _________ / ______________________
                   (Month)       (Year, 4 digits)
