Filtrix for Windows Order Form

Order date: ______________________

Name of end user (person, not company): ___________________________________________

Company/Organization: _____________________________________________________________

Address: _________________________________________________________________

City:____________________________________ State: _________ Zip: ___________________


Telephone:_______________________________ Fax: ____________________________________

Email:___________________________________

Mailing address (if different): ___________________________________________________

City:____________________________________ State: _________ Zip: ___________________





Platform:  Win 95/98/2000/NT/XP  

		    ______ licenses @ $89 per license: ____________

  Upgrade @ $48.00 per license (include all per site): ____________

						Total: ____________


NOTE: NO RETURNS OR EXCHANGES. 


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