AUSTRAPAY V2.3 REGISTRATION/ORDER FORM

For credit card or multiple                 For cash or cheque orders
product orders send to:                     for AUSTRAPAY only send to:

ARK ANGLES                                  PC ANSWERS (AUSTRAPAY Orders)
P O Box 190                                 P O Box 273
Hazelbrook  NSW  2779                       Paddington  NSW  2021
AUSTRALIA                                   AUSTRALIA
Phone: (047)588100 or Intl+61-47-588100     Phone: (02)3613763
Fax:   (047)588638 or Intl+61-47-588638     Intl : +61-2-3613763
CompuServe: 100237,141

From: Company: __________________________________________________________

      Contact: __________________________________________________________

      Address: __________________________________________________________

      Address: __________________________________________________________

      State:   _______   Postcode: _______   Phone: (_____)______________

                                             Fax:   (_____)______________

I obtained my copy of AUSTRAPAY from:____________________________________


COMPANY NAME for purposes of Group Certificate etc. is:
      ____________________________________________________ (max 40 chars)

Disk Type (mark one):  5.25"  360K[ ]  1.2M[ ]    3.5"  720K[ ]  1.44M[ ]

Please send .... copy(s) of the latest version of AUSTRAPAY + EFT facility
+ Operators Manual + 3 months installation support.

Our company currently employs:          1-10  employees  @ $150  ________
                                       11-50             @ $450  ________
                                       51-100            @ $700  ________

Plus 12 months support & maintenance:   1-10  employees  @ $100  ________
                                       11-50             @ $150  ________
                                       51-100            @ $200  ________

                                                                 --------
                                                        TOTAL  $
                                                                 ========

[ ] Bankcard    [ ] Mastercard    [ ] Visa    [ ] Cash/Cheque/Draft/Order

Credit Card No  _______ _______ _______ _______   Expiry Date ____ / ____

Cardholder Name _________________________________________________________

Signature       _______________________________   Date __________________