****** FlexTouch Fax Order Form ******

Please fill out and print this form, then fax it to:

888-353-7276 (toll free), or
425-392-0223 (international regular).

To have your order processed successfully, please fill out this form as 
completely as possible. Please note that fax orders take more time to be 
processed, so for the quickest and most reliable registration you may 
also order FlexTouch online via SECURE order form:

https://www.regnow.com/softsell/nph-softsell.cgi?item=2888-1

*** FlexTouch Order Form begins ***

Product ID: 2888-1

First Name: ________________________________________________________

Last Name: _________________________________________________________

Company: ___________________________________________________________

Billing Address: ___________________________________________________

____________________________________________________________________
  
City: ______________________________________________________________

State/Province: ____________________________________________________

Zip/Postal Code: ___________________________________________________

Country: ___________________________________________________________
  
Phone: _____________________________________________________________

Email Address (REQUIRED): __________________________________________
 
Quantity ($19.95 each): ____
 

*** Payment Information  ***

Name on Card: _____________________________________________

--- Type of Credit Card ---

Visa:             ___

Mastercard:       ___

American Express: ___

Discover (Novus): ___

Eurocard:         ___
      
Card Number: ____________________________________

Expiration Date: Month _____    Year(4 digits) __________

*** FlexTouch Order Form end ***

Thank you for registering FlexTouch!