ORDER INFORMATION
When ordering by Phone, FAX, or E-Mail, you must provide the following information.   You can print this form with the web browser that you are using to view this document.  The following information is required to process your order. All of the information you supply below will remain confidential, and will not be resold, leased, or otherwise divulged.



Name:
(as it appears on your Credit Card)

Company:
(Enter N/A if not applicable)

 

Billing Address - (the address your credit card bill is sent to)
Street:

City:

State:

Postal Code:

Country:

Daytime Phone number:

E-mail Address:

Credit Card Information
Type (Visa, Mastercard, American Express, Discover):

Account Number:

Expiration Date:

Software to Order
Title:

Quantity:

Total Dollar Amount:


I agree that I am the lawful holder of the credit card described above, and agree to pay the amount I authorize according to the agreement between the card issuer and me. I understand that a charge from setSystems for the amount I authorize will appear on my statement. I further understand that all details of this transaction will be logged and may be used for investigation of fraudulent transactions.


_________________________
Signature (if faxed)

 

________________________
Date