Y2KPATCH Sales Order Form

FAX or Send by Postal Mail

INVOICE NUMBER

Official Use Only

Company:

First Name:

Last Name:

Street Address:

City:

State/Prov:

Zip/Postal Code:

Country:

Phone:

E-Mail:

Return to:

Dennis R Blanks Computer Consultant

2221 South Palm Grove Ave

Los Angeles, CA 90016

1(323)732-2996 Fax 1(323)732-0255

Please Supply the Following

Each

Total

Y2KPATCH user/site

License(s)

Handling Charges

$00.00

Total Enclosed

Dennis R Blanks Computer Consultant upon the receipt of this sales order will issue an Invoice. Goods will be sent immediately upon payment of the invoice.

Signature Date.

I agree to the above terms and conditions.

Payment Method

Credit Card. Check one of the following:

Visa (13 or 16 Numbers) Master Card (16 Numbers) American Express(15 Numbers)

Card No:_______________ Exp. Date:_____

Name of Card Holder:____________________

Signature of Card Holder:_________________

Check enclosed or forthcoming

Make checks Payable to: Dennis R Blanks Computer Consultant

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