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Ship to
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__________________________
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Bill to
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_____________________________
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Address
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__________________________
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Address
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_____________________________
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__________________________
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_____________________________
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City
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__________________________
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City
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_____________________________
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State
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_____ Zip Code
____________
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State
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______ Zip Code
____________
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Please check one of the following ways of payment:
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___ Bill Us: P.O.
#_______________
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___ Prepaid Check enclosed (Payable to InfoWorks
Technology Company)
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___ Charge Us:
___
Visa ___ Master
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Name of the Credit Card
Holder
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__________________________
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Account Number
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__________________________
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Expiration Date (mm/dd/yy)
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____/ ____/ ____
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