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Text File  |  1995-04-12  |  2KB  |  61 lines
  1.                          MILLENNIUM MEDIA GROUP
  2.                                ORDER FORM
  3.                      
  4.  
  5. Name (Please Print) ________________________________________________________
  6. Address ____________________________________________________________________
  7. City __________________________________ State __________ ZIP _______________
  8. Daytime Phone Number (_______)______________________
  9.  
  10.  
  11.                         [ ] H.U.R.L.    DOS CD-ROM                 $39.95
  12.  
  13.                                                     SHIPPING:        5.00
  14.  
  15.                                           PA State Sales Tax:  $____________
  16.                      (PA residents must include 7% sales tax)
  17.                                              Amount enclosed:  $____________
  18.  
  19. Mail or fax this form to:
  20.  
  21.           Millennium Media Group
  22.           234 N. Columbus Blvd.
  23.           Philadelphia, PA  19106
  24.           Fax #:  (215) 625-2567
  25.  
  26. Or call 1-800-U-WANT-IT (1-800-892-6848), for orders only.
  27.  
  28. Type of payment:  [ ] Check  [ ] Visa  [ ] MasterCard
  29.  
  30. Card number: _________________________
  31.  
  32. Expiration date:  _____/_____
  33.  
  34. Signature:   ________________________________________
  35.  
  36.  
  37. Where did you get this H.U.R.L. Shareware Edition from?
  38.  
  39. Downloaded from:
  40. [ ]        Apogee BBS
  41. [ ]        ExecPC BBS
  42. [ ]        Other BBS: Name: ________________________________________________
  43. [ ]        Compuserve (CIS): Forum Name: ___________________________________
  44. [ ]        America Online (AOL)
  45. [ ]        Prodigy
  46. [ ]        Genie: RoundTable  (RT) Name: ___________________________________
  47. [ ]        Delphi: Special Interest Group (SIG) Name: ______________________
  48. [ ]        Internet FTP Site: Site Name: ___________________________________
  49.  
  50. Purchased from:
  51. [ ]        Catalog Vendor: Vendor Name: ____________________________________
  52. [ ]        Retail (Store, flea market, computer fair): 
  53.                                 Vendor Name:  ______________________________
  54. [ ]        Ordered it from MILLENNIUM directly
  55.  
  56. Other:
  57. [ ]        A friend gave it to me
  58. [ ]        Where: __________________________________________________________
  59. [ ]        I don't remember
  60.  
  61.