GeoMagix Order Form

Please type in the following information, then FAX form with 
credit card number or mail form via post with payment:

______________________________________________
Registration Name (must be at least 11 characters)
Registration Name MUST BE the name of the individual or company named below

 

_____________________________________________________
Full Name (first, middle initial & last):

_____________________________________________________
Address: 
         
_____________________________________________________


_____________________________________________________

         
_____________________________________________________

Country: 
	   _____________________________________________________

E-mail address: 
	          ______________________________________________

[Telephone (with Area Code)]: 
		                  ________________________________

[Fax (with Area Code)]: 
		                  ________________________________

Version you are using: __•____

Geomagix license/password: US$30	FAX: (303) 278-4007
Payment:
	[ ] Check/money order enclosed (payable to Interpex Limited)
	[ ] VISA credit card (charged in US currency)
		VISA number:
			       ______ ______  ______  ______
		Expires:     
			   ___/___
		Cardholder name:
				     ________________________________

		Signature:
			     ______________________________________

[Comments/Suggestions]: 
		            _____________________________________

_____________________________________________________________

Please mail this form to the address below.  Thank you for
registering!


	Interpex Limited
	P.O. Box 839
	Golden, CO 80401-0839
	USA
	FAX: (303) 278-4007		www.interpex.com