Blossoms of the East Screen Saver Order Form

Date:________________________________________________________________

Company: (if applicable)_________________________________________________

Name:________________________________________________________________

Address:_____________________________________________________________

_____________________________________________________________________

City:________________________________State/Province:_________________

Postal/ZIP Code:_____________________Country:________________________

Phone:_______________________________________________________________

Fax:_________________________________________________________________

E-Mail:______________________________________________________________

Alternative E-mail:_____________________________________________________

Once your payment is received you will receive your 
personal registration key within 24 - 48 hours.

Product                                     

Blossoms of the East v2.0 Screen Saver ........................ US$10.-

North Carolina Residents please add 6% sales tax ......  US$ __________

Total ...............................................................  US$ __________

For credit card payment only:

Circle one: Visa / MasterCard / Discover / American Express / Diners

Credit card number: _________________________________________________

Expiration date: ____________________________________________________

Authorization signature: ____________________________________________

Once your payment  is received you will receive your 
personal registration key within 24 - 48 hours.