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Arkel Products, Inc
4931 NW 116th Avenue
Coral Springs, Florida 33076

Order Form

First Name: __________________________       Last Name: __________________________

Street Address: ______________________________________________________________

City: ______________________________________________________________________

State: ________________         Zip Code: ____________         Country: _________________

Day Phone: ________________________         Evening Phone: ________________________

Handheld Device and OS Version: _______________________________________________

Palm User Name: ____________________________________________________________
(Required - Used for generating registration code to enable software)

Email Address: ______________________________________________________________
(Used for sending out registration code and for update notices)

Choose Shipping Option of Registration Code:   [   ]  Email    [   ]  Postal Mail

Choose Payment Option:
[   ]

Check or Money Order
             (Please make payable to: Arkel Products, Inc)
[   ]

Credit Card
             Name on Card: ____________________________

             Credit Card Number: ________________________

             Expiration Date (MM/YY): ___________________

             Card Type:  [   ] Visa    [   ] MasterCard
                                [   ] American Express    [   ] Discover
Product Name                                                     Qty              Price (US $)                           Total
Pregnancy Assistant _____ $10.00 $__________
Subtotal $__________
Sales Tax (FL Only)* $__________
Shipping and Handling** $__________
Total $__________

I authorize Arkel Products, Inc to charge the appropriate amount as noted above for providing
the appropriate registration code(s) as listed above. The Registration Code(s) will be shipped
or emailed as specified in the order form.

Signature: _______________________         Date: ________________

* Sales Tax Florida
Sales tax is only required for Florida Residents. The current tax rate is 6%, but a number of counties have an additional discretionary sales surtax. Please give us a call to help determine the appropriate amount of sales tax.

** Shipping and Handling
Please include $1.00 for shipping and handling if you wish to have your Registration Code(s) sent to you via the Postal Mail.

Copyright © 2002-2004 Arkel Products, Inc. All rights reserved.
Palm OS ® is a trademark of Palm Computing Inc. Other third party product names and brands identified on these pages may be trademarks or registered trademarks of their respective holders.