Mail Order Form

Print this form, fill it out completely, and send with a check, money order, or credit card information, to:

International Number Registry

Adress to be published soon

Name:
Organization:
Email:
Street:

City:		State:	ZIP:
Phone:
Payment Type:	Credit Card	Check	Money Order

Credit card information
Card type:	Mastercard Visa American Express Discover Diner's Club
Card number:	eg: 1234-5678-9012-0000
Expiration:	eg: 09/98
Cardholder name:

Products

Product		Qty	Price
	INR Registered Real Number		$ 45.00
	INR Registered Prime Number		$ 45.00
	INR Registered Rational Number		$ 45.00
	OH Residents add 5.75% sales tax
	shipping: add $3.00 per number
	Total

Names
use this space to designate the names for the numbers