NetSwitcher Mail/FAX Order Form

Please use this form when you mail or FAX your order - Print out and fill in information

PLEASE PRINT CLEARLY!!!! Items in BOLD Italics are REQUIRED.

Name:_________________________________________________________

Company:______________________________________________________

Address:_______________________________________________________

City:__________________________  State (if applicable):_______________

Zip or Postal Code:________________  Country:_______________________

Telephone number:_______________________________________________

EMAIL Address:_________________________________________________

(Please include your EMAIL address so we can send your license - WE DON'T SEND SPAM or sell EMAIL addresses!!)

Quantity Ordered: _______ (US$19.95 each, a discount will be applied for qty. 10+)

Payment Option: (__Cash or Check Enclosed)( __Visa) ( __MasterCard)(__AMEX)(__DISCOVER)

Card Number (Please double-check the number!) ________________________________

Card Expiration Date: ________________  Card Verification Value (CVV): _______ (3 digit number)

(See https://www.netswitcher.com/CVV/  for more information.   This is REQUIRED!)

Cardholder Name:________________________________________________

Cardholder Signature:_____________________________________________

Please make any check payable to and mail to: 

J.W. Hance
1950-18 E Greyhound Pass, Suite 305
Carmel, IN 46033 USA
FAX credit card orders to:  J.W. Hance  (Visa/MasterCard/AMEX/DISCOVER ONLY)
(Please note that this FAX number does not accept unsolicited advertisements.)

Please note any special instructions or comments below: