PRODUCTS ORDER FORM (Fill out form completely)

Name:_______________________________  Title:______________________________
Address:____________________________  City:_______________________________
State/Province:_____________________  Zip/Post Code:______________________
Country:____________________________  Date:_____/_____/_____
Email Address:______________________  IP Address:_________________________
I have read and agree to the terms of the license agreements.
Signature:__________________________
 Referrer:___________________________
Product Qty Price(ea)  S&H Total
Online Dice Mini Dice [__] $9.95   _______
Online Dice Basic Dice [__] $29.95   _______
Online Dice Role-playing Dice [__] $49.95   _______
Online Dice Romance Dice [__] $49.95   _______
Online Dice Seduction Pkg. [__] $149.95   _______
Online Dice SDK [__] $89.95   _______
Shipped on CD [__]    $7.00 _______
* Canadian Orders, Add $8.00 per copy _______
* International Orders, Add $12.50 per copy _______
* Add appropriate sales tax _______
       
Total Enclosed _______

note: prices subject to change without notice

[_] Traveler's Check [_] Money Order [_] Cashier's Check Payable to: Dan Mustaine

Mail Completed form with Payment to USA:

Dan Mustaine
537A Mapletree Ln.
Urbana, OH 43078