------------------------------------------------------------------------------ REGISTRATION AND ORDER FORM ------------------------------------------------------------------------------ Mail to: GoldPax Software P.O. Box 1576 Royal Oak, MI 48068-1576 ------------------------------------------------------------------------------ PRICE PRICE PRODUCT QTY EACH EXTENDED ----------------------------- --- ----- --------- Single User Object License ___ $35.00 $ _______ Single User Object License with Source Code ___ $60.00 $ _______ Registered User Obtaining Source Code ___ $35.00 $ _______ Registration Number ______________________________ ( Required ) Multi-User Corporate License ___ $500.00 $ _______ SUBTOTAL $ _______ Michigan orders, add sales tax (4%) $ _______ TOTAL $ _______ ------------------------------------------------------------------------------ Name: _______________________________________________________________ Address: _______________________________________________________________ _______________________________________________________________ City: _______________________________________________________________ State: ____ Zip: ______________ Phone: (______) - ______ ____________ ------------------------------------------------------------------------------ Comments: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ------------------------------------------------------------------------------