ORDER SECURE FORM

ORDER YOUR

OWN SECURE FORM

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The price for a form like this is $129.00. It covers formatting and setup of your form (with a link from your Master Page), as well as hosting and maintenance for 1 full year.

Your Name

E-mail (required)

Your URL . It should start with http://

Please enter all instructions and details you want to appear on your order form;
Your company name, address, phone, fax, products and prices (one by one), S&H costs, Your State tax, types of credit cards you honor etc. Include all additional information you would like to have on your form as well.

Check/Money orders

Enter the total US$ of your check:

For Credit Card orders use form below.

Please write down, or print the payment information if paying by check/money order:

Make your Check or Money Order payable to Now Intermedia Inc., and send to:

Now Intermedia Inc.,

P.O. Box 420856

Summerland Key, FL 33042-4805

USA

IMPORTANT: Please include your e-mail address in the memo field of your check for speedier processing.

Credit Card orders MASTER CARD

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CREDIT CARD INFORMATION

* Please use the billing address where your credit card statement is mailed.

MasterCard Visa	Card Number:
	Expiration Date: (mm/yy)
	CVV: (last 3 digit number on the back of your card)
	Total US$ amount to be charged to your card.
Your Name (exactly as on credit card):
*Address:
Phone Number:
Country:
City:		State:	Zip
Other Comments: To order please click on Submit Order button (only once)

ONLINE SINCE 1996