Postal Mail Order Form
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To send your order via postal mail please print and mail the completed form to:

Mystik Media
296 Captain Beam Blvd
Hampstead, NC 28443

Product and Purchase Information:

Merchant Name: Mystik Media
Description:  Blaze ImgConvert
Purchase amount: $29.95


Billing Address Information:


Street (Line 1): ________________________________________________________

Street (Line 2): ________________________________________________________

City: ________________________________________________________________

State / Province: _______________________________________________________

ZIP / Post Code: _______________________________________________________

Country: _____________________________________________________________

Phone: ______________________________________________________________

E-mail: ______________________________________________________________


Payment Type

Select your type of Payment:

___Personal or business check. It usually takes 2 to 5 business days after receipt of the check for the bank to process the check. Once the check has been processed the activation code is e-mailed to you within 48 hours. (Attention: There is a $25.00 charge for all returned checks.)

___Cashiers Check or Money Order

___Credit Card (Please ensure the address above matches the Credit Cards business address. 


Credit Card Information

If paying with a credit card please supply the following information:

Card Type: ____________________________________________________________

Card Number: _________________________________________________________

Expiration Date: ________________________________________________________

Signature: _____________________________________________________________

Thank You For Your Order!