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:
9301 Kalamalka Road
Coldstream, BC V1B 1K9

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)

Notes:
(Include any other details about the order.)
Where did you hear about our software? Please be descriptive.
Please check the box on the left if you do not wish to receive news and product updates for this software.