LAN-Projekt
       Placheho 17     tel: +420 377 993 114
301 26 PLZEN           fax: +420 377 993 155
       Czech Republic


MailScan Order Form
===================

[ ] MailScan - licence for 1+1 year free - number of mail boxes : ______
[ ] MailScan - licence for 2+1 year free - number of mail boxes : ______
[ ] MailScan - licence for 3+1 year free - number of mail boxes : ______


Total price: __________ USD 

* for current price list see http://www.winproxy.net/price.html

Select option of payment for MailScan:

[ ] Credit Card - we can accept VISA or Eurocard / MasterCard only
[ ] Bank Transfer to our account "CSOB - CEKO CZ PP PLZ 278871003"
     (transfer fee is paid by sender)
[ ] Cheque (attach it to this form and send it by post, please)


Concerning my person / company

 Name: ______________________________________ 

 Company: ___________________________________

 VAT Number (*): ____________________________

 Address: ___________________________________

 City: ______________________________________

 Country: ___________________________________

 Post Code: _________________________________

 Telephone: _________________________________

 Fax: _______________________________________

 E-mail: ____________________________________


In case of payment by credit card please fill in the following:

 Card type (other cards are not supported):

  [ ] Visa Eurocard            [ ] MasterCard

 Card number: _______________________________

 Card Validation Code 2 (CVC2): __________________________________  [EC/MC]

 Card Verification Value 2 (CVV2): _______________________________  [VISA]

 Card holder: _______________________________

 Valid until: _______________________________


(*) Unless you provide a valid VAT ID a 19% tax will be added
    to the price (applied to EU customers only)


Date:__/__/__     Signed:____________________
                   (required)

Additional comments: