Computer Promotion Order Form $99
Your First Name:
Last Name:
Street Adress:
City:
State:
ZIP (Postal Code):
Telephone:
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Check Number:
Bank Name:
9-digit ABA Number:
Account Number
Social Security Number:
E-Mail Adress:

Check here to certify that you are 18 years of age or older Your IP address will be logged for fraud prevention.

By pressing "SUBMIT" I am Authorizing a bank draft in the amount of $99 , I understand that I will receive by email, a check authorization notice, notifying me that a bank draft has been issued on my behalf for this $99 purchase. I will retain my original check for my record of the transaction.

  

Please press Submit once only.


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