Arkel Products, Inc
First Name: __________________________
Last Name: __________________________
Street Address: ______________________________________________________________
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)
Name on Card: ____________________________
Credit Card Number: ________________________
Expiration Date (MM/YY): ___________________
Card Type: [ ] Visa [ ] MasterCard
[ ] American Express [ ] Discover
Price (US $)
Total Pregnancy Assistant
$__________ Sales Tax (FL Only)*
$__________ Shipping and Handling**
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.
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