Safe Data Backup Order Form Name: ______________________________________ Address: ______________________________________ City: ________________________ State: __ Zip Code: __________ Country: ______________ Phone: _________________________________________ E-mail address: ________________________________ How did you obtain Safe Data Backup? ________________________________________________ Any improvements that you would like to see? ________________________________________________ ________________________________________________ ************************************************ Safe Data Backup License: (choose one) ____ New License $24.95 Upgrade $14.95 Program on CD: (Optional) + ____ Within United States $10 Outside United States $15 Total Payment Enclosed: = ____ If paying by check, please make it payable to "Beiley Software Inc.". US funds only please. ************************************************ Please send payment to: Beiley Software Inc. 1161 North Dustin Lane Chandler, AZ 85226 E-mail: www.beiley.com/contact.html Phone: (480) 705-0129 If paying by credit card please fill in the following: Card Number:________________________________________ Circle one: Visa MasterCard Discover Amex Expiration Date (mm/yy):___/___ CVV2 (Security Code):_____ Cardholder's Signature:______________________________