FAX ORDER FORM (Print page, fill in, and fax to us)

Please supply the NEW 2005 Worldwide Directory of Distributors:
Print Edition @ $595: ____ or the Electronic Edition @ $995:____ (includes Adobe Acrobat Electronic Edition, plus spreadsheet file of database)

Ship via:
[ ] Priority Mail (adds $7 for US, $30 abroad)
[ ] FedEx (adds $30 for US, $60 abroad)

Send the directory to:

Name: __________________________________________________________________

Company: ______________________________________________________________

Address: ________________________________________________________________

City, Post Code, Country: ___________________________________________________

Telephone: ______________________________________________________________

E-Mail: __________________________________________________________________

I am paying by: [ ] check in US dollars [ ] American Express [ ] VISA [ ] Mastercard

If paying by credit card, here is my card information:

Card Number: ____________________________________________________________

Expiry Date: ___ ___ / ___ ___

Name on Card: _____________________________________________________________

Signed: __________________________________________________

Please fax this completed form to PhorTech International at +1 (650) 594-9846