ESG Wizards Credit Card Fax Order Form
Please print this form, fill it in clearly and fax to: +1 619-275-1793

Name: ___________________________________________________________________
Company: ___________________________________________________________________
Telephone: _______________________ Fax: _______________________
Email Address: _________________________________________________________
Mailing Address: _________________________________________________________
_________________________________________________________
City: _______________________ State/Province: _________________
Country: _____________________ ZIP/Postal Code: _______________

Product Ordering and Total Amount:

Number of MrSID Tools for ER Mapper Pro Licenses: ________________ (US$195 each)
Number of MrSID Tools for ER Mapper Image Compressor Unlimited Licenses: ________________ (US$195 each)
Total price (US$): ________________

Credit Card Information (print clearly):

Card Type: VISA _______ MasterCard _______ American Express _______
Credit Card Number: ___________________________________________
Expiration Date: _______________
Name on card: _________________________________________
Signature: _________________________________________
Shipping: Product(s) delivered via web download link in password-protected ZIP format.