IXSeg2Segy Order Form

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

REGISTRATION NAME : __________________________________________
                      (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)]:     ________________________________

Version you are using: v (e.g. 3.00)	 ___•______

IXSeg2Segy license:                       US$   299
Total Payment Due:                        US$ __________

Payment by:
	[ ] Check/money order enclosed (payable to Interpex Limited)
	[ ] VISA / MasterCard (charged in US currency)
		PLEASE FAX LEGIBLE COPY OF FRONT & REAR OF CREDIT CARD!!
		VISA / MasterCard number:

		 ________ ________  ________  ________	Expires:    ___/___

		Cardholder name:     ________________________________

		Signature:
			     ______________________________________

[Comments/Suggestions]:  _____________________________________________________


______________________________________________________________________________

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

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