************************ * BILLING INFORMATION * ************************ Full Name ____________________________________________________ Company ____________________________________________________ Address ____________________________________________________ ____________________________________________________ City _______________ State/Province _______________ Zip/Postal _______________ Country _______________ Phone _______________ Fax _______________ E-mail ____________________________________________________ Which product are you purchasing? [ ] Flux $14.95 [ID 139105] [ ] Flux Deluxe CD-ROM $17.95 [ID 139134] *************************** * CREDIT CARD INFORMATION * *************************** Card Type: [ ] Visa [ ] MasterCard [ ] American Express [ ] Discover [ ] Diner's Club [ ] Other Card Number ____________________________ Expiration Date ____________________________ Name on Card ____________________________ Card Issuer ____________________________ If your billing address is different from that of your desired shipping address, please print another copy of this order form, clearly label it BILLING and fill out the necessary information.