Arkel Products, Inc |
Order Form
First Name: __________________________
Last Name: __________________________
Street Address: ______________________________________________________________
City: ______________________________________________________________________
State: ________________
Zip Code: ____________
Country: _________________
Day Phone: ________________________
Evening Phone: ________________________
Handheld Device and OS Version: _______________________________________________
Palm User Name: ____________________________________________________________
(Required - Used for generating registration code to enable software)
Email Address: ______________________________________________________________
(Used for sending out registration code and for update notices)
Choose Shipping Option of Registration Code:
[ ] Email [ ] Postal Mail
Choose Payment Option:
[ ]
Check or Money Order
(Please make payable to: Arkel Products, Inc)
[ ]
Credit Card
Name on Card: ____________________________
Credit Card Number: ________________________
Expiration Date (MM/YY): ___________________
Card Type: [ ] Visa [ ] MasterCard
[ ] American Express [ ] Discover
Product Name
Qty
Price (US $)
Total
Pregnancy Assistant
_____
$10.00
$__________
Subtotal
$__________
Sales Tax (FL Only)*
$__________
Shipping and Handling**
$__________
Total
$__________
I authorize Arkel Products, Inc to charge the appropriate amount as noted above for providing
the appropriate registration code(s) as listed above. The Registration Code(s) will be shipped
or emailed as specified in the order form.
Signature: _______________________
Date: ________________
* Sales Tax Florida
Sales tax is only required for Florida Residents. The current tax rate is 6%, but a number of counties have an additional discretionary sales surtax. Please give us a call to help determine the appropriate amount of sales tax.
** Shipping and Handling
Please include $1.00 for shipping and handling if you wish to have your Registration Code(s) sent to you via the Postal Mail.
Copyright © 2002-2004 Arkel Products, Inc. All rights reserved.
Palm OS ® is a trademark of Palm Computing Inc. Other third party product names and brands identified on these pages may be trademarks or registered trademarks of their respective holders.