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TOTAL $__________   *Includes Shipping and Handling
 

Personal Information

Name_________________________________

Address _____________________________________________      

City _____________________________

State___________________     Zip Code_________________

Phone Number __________________________ E-mail Address (Required) __________________________

Shipping Address (If different than above)

Name___________________________________

Address ______________________________________________      

City _____________________________   State__________________   Zip Code_______________

Method of Payment

_____Visa2.gif (654 bytes)   _____Mastercard1.gif (521 bytes)   ______amex-logo.gif (1110 bytes)    ____discovercard.gif (1804 bytes)_____ Check    _____ M.O.

Card Number ________-________-________-________

Expiration Date _____-_____ (mm/yy)             Cardholder Name ______________________________

Cardholder Billing Zip Code___________         Signature: ___________________________________

Fax To: 1 (727) 526-3203

Print & Mail or Fax Order Form and Payment To: 
Information Net Source Corp.
2116 Montana Ave. NE
St. Petersburg, FL 33703


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