To send your order via fax please print and fax the completed form to:
775-924-4436
Product and Purchase Information
Merchant Name: Mystik Media
Description: Blaze ImgConvert
Purchase amount: $29.95
Billing Address Information
Name:_______________________________________________________________
Street (Line 1): ________________________________________________________
Street (Line 2): ________________________________________________________
City: ________________________________________________________________
State / Province: _______________________________________________________
ZIP / Post Code: _______________________________________________________
Country: _____________________________________________________________
Phone: ______________________________________________________________
E-mail: ______________________________________________________________
Credit Card Information
Only credit card orders can be received via fax. Please supply the following information:
Card Type: ____________________________________________________________
Card Number: _________________________________________________________
Expiration Date: ________________________________________________________
Signature: _____________________________________________________________
Thank You For Your Order!