MightyFax Order Form
Please use the Print button in your browser to print this form. Fill out the printed form, and then send or fax it with your payment to:		BMT Micro PO Box 15016 Wilmington NC 28408 Fax: 910-792-1889

Name (Please Print)
Address
City			State / Province
Zip / Postal Code			Country
Phone #
Fax #
E-Mail Address
Alternate E-Mail

Item Description	Price Each	Quantity	Price
MightyFax	$19.95 (US)
North Carolina Residents please add 6.5% sales tax
Total Amount Enclosed

Payment Method (circle):  CASH   /   CHECK   /   MONEY ORDER   /                                        VISA   /   MC   /   DISCOVER   /   AMERICAN EXPRESS

** Please make check or money order payable to "BMT Micro" ** All checks or money orders in US Funds only

Please add the following information for credit card orders: Card# _________________________________    Exp. Date: ____ / ____ EXACT Name on Card: _________________________________________ Signature ____________________________________________________