QuickMirror Order Form

As a valued customer, your information is considered confidential and will not be shared with or distributed to any third party. Please fill in the information below. Type, or print neatly in English. All information is required unless specified otherwise.

Name: _____________________________________________ Date:___-___-_______

Company (optional): ____________________________________________________

Address: ______________________________________________________

City, State, Zip: ______________________________________________________

Country: ________________________________________________

Day Phone (optional): ________________

Email address : _________________________________

QuickMirror Licenses:

1 to 20 computers: ____ computers at $25 each = ________, OR

21 to 50 computers: ____ computers at $23 each = ________, OR

50+ computers: ____ computers at $20 each = ________, OR

educational site license at $3000 = ________, OR

corporate site license at $5000 = ________

Total payment U.S. $ = ________ - total US$

You MUST specify your email address above so we can email your registered version (you may also download from our web site any time).

Make check or money order (in U.S. dollars drawn on a U.S. bank) payable to QuickMirror. We also accept cash in U.S. currency.

If you fail to send the correct payment, your order may be returned.

Orders will be processed within 10 days after they are received. You will be mailed a printed version of the license agreement, and a license certificate as proof of your purchase containing the number of licenses purchased and registration number.

You will receive the registered QuickMirror version, and can download updated registered versions as they become available.

By sending us your order, you are agreeing to the License Agreement included in the order.txt file of the QuickMirror trial version you have used.

Mail this order form and payment to:

Michael Mathews
4612 Church Street
Metairie, LA 70001-3359