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| Name: _________________________
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| Email: _________________________
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| Company (optional): ______________
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| Address: ______________________
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| City: __________________________
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| State: __________
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| Country: ____________
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| Zip: _________
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| Phone: (___) ____- ______
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| ( ) I am enclosing a check or money order for $379. Please note that we do not accept checks by fax, so if you are paying by check or money order you must mail it in to the address above.
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| ( ) I want to charge this purchase to my Credit Card
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I authorize The Internet Marketing Center to charge $379 to my credit card for the
purchase of the Mailloop software