CGI Script Installation Center Order Form

Name:
E-Mail:
Phone:
Name of Script to Install:
Script License Number:
(if applicable)
Installation Charge:
(Price will be confirmed before installation.)
URL of page where script can be downloaded:
Comments:
Payment Type:

MasterCard Visa Discover

Credit Card number:


Your card will be billed manually by:
Mousel's Self-Defense Academy

Expiration Date:
Checks or Money Orders can be sent to: Tim Mousel, 747 N. Shepherd, Suite 400,
Houston, TX 77007
Your FTP Address: (name.com)
Your homepage url if different than ftp address: (homepage.com)
FTP Username:
FTP Password:
URL to your webhost support area:

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