BLUEBELL DATA MAIL ORDER FORM

Print & Mail to:

Bluebell Data
PO BOX 1174
Swindon
SN2 1XE

Please make cheques payable to Bluebell Data

I am paying by [ ]Check [ ]Money Order [ ]Credit Card (Also fill out fields below)

Name ________________________________________________

Address_______________________________________________

City_____________________

County / State_________Postal Code / Zip_____________

Country_____________________

Phone Number _________________________________

Email Address__________________________________________

Product:______________________________________________

Sub Total:______________________________________________

Credit Card Order [ ] VISA [ ]MasterCard [ ]Switch   (Your Statement will show 'Bluebell Data')

Name on Card________________________________________________

Credit Card No. _________________________________Exp Date __________

Valid From Date __________

Issue Number (switch): __________________

Sub Total ________

Carriage________  Free

Charge this Amount: __________________

Signature ______________________________________________________

A note to our overseas customer Cheques must be drawn on a UK bank in sterling, see your bank for details.