International
Fax Order Form

Ship To:
  First Name:  
  Last Name: 
    Company: 
    Address: 
             
       City:  State:  Zip: 
    Country: 

Bill To:
    Address: 
             
       City:  State:  Zip: 
    Country: 

      Email: 
      Phone:  
        Fax: 

Electronic E6-B for Palm OS: 0 1 2 3 4 5 @ $24.95 each (e-mail delivery)

Electronic E6-B for Palm OS Upgrade: 0 1 2 3 4 5 @ $12.95 each (e-mail delivery)

Electronic E6-B for Pocket PC: 0 1 2 3 4 5 @ $24.95 each (e-mail delivery)

Electronic E6-B for Pocket PC Upgrade: 0 1 2 3 4 5 @ $12.95 each (e-mail delivery)

Portable Electronic CoPilot for Pocket PC: 0 1 2 3 4 5 @ $49.95 each (e-mail delivery)

Additional Licenses: 0 1 2 3 4 5 @ $9.95 each (e-mail delivery only)

CD-ROM Delivery: 0 1 2 3 4 5 @ $5.00 each (select delivery method below)

Shipping Method: 
        E-Mail - Free
        Parcel Post/Global 
		Priority Mail, $20
        Other
      

Global Priority Mail is available these countries in Western Europe or Pacific

Please email: sales@niborex.com for a FedEx shipping rate quote.

Notes: ___________________________________________ 

Order Total (including shipping & handling): _________________
(All prices are $US)
(You pay applicable customs duty & tariffs when merchandise arrives in the destination country)

Card Type: VISA MasterCard American Express
Credit Card Number: Exp. Date:
Credit Card Number Security Code:

Signature _______________________________________

I agree not to re-export the Niborex software.

Signature _______________________________________ Date ____________