CyberMatrix FAX/Mail Order Form

Please fill in the form below, print it out, and Mail it with a Check or Money Order in US Dollars (or Canadian dollars for Canadian customers),
made out to CyberMatrix Corp. Inc. at:
3104-30th Ave
Suite #224
Vernon, B.C. V1T 9M9

Program Name

 

Number of licenses
i.e. 10 Seat etc. enter Site for a site license

 

Price

Shipping

GST/HST

[Canadian customers only. NB, NL, ON - 13%, NS - 15%, Other 5%]

7% PST

[British Columbia customers only]

Billing Information:

Email Address:
Must be filled in for products shipped by Internet

Name:
Exactly as it appears on credit card

Company Name:
(optional)

Address:
Exactly as it appears on your statement
(make sure to include your country)

Shipping Address:
(If different from billing address.)

Phone Number:

Credit Card:

Credit Card #:

Exp Date

Card Identification #:
(Number printed in black ink above the embossed card number - Amex only)

Purchase Order# (P.O.):
(Only if using a purchase order.)
(Include your standard credit references form.)

Notes:
(Include any other details about the order.)

Where did you hear about our software? Please be descriptive.
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