Customer Email Address (or FTP site): _________________________________

Payment Method: _____Check _____Money Order _____Cash

Image Format: _____JPG (Jpeg) _____GIF _____BOTH (Jpg & Gif) * (no extra charge)

Method to Send SCANS:
--by Email: _____ONE AT A TIME (Default) _____ZIPPED _____MIME (Base64)
--by Diskette(s): ______ 1-5 diskettes, add $5.95 ______ 6-10 diskettes, add $9.95 ______ 11-20 diskettes, add $19.95
(addtional charges are for additional cost & postage) * (include address info below for return mailings):

Name: ________________________ Address: _______________________________
City: __________________________ State: _______________ Zip Code: ___________
Country (if outside US): _______________

Pictures/Documents to be Returned to Customer ( Y / N ): ___SASE Enclosed ___Return Postage included in Payment

Pictures/Documents Description ... Size (1) ... Add. Sizes(.25ea) ... Title Text (free) ... Size Limit (KB) ... Unit / Item Price
01______________________________________________________________________ $4.00 ________
02______________________________________________________________________ $2.00 ________
03______________________________________________________________________ $2.00 ________
04______________________________________________________________________ $2.00 ________
05______________________________________________________________________ $2.00 ________
06______________________________________________________________________ $2.00 ________
07______________________________________________________________________ $2.00 ________
08______________________________________________________________________ $2.00 ________
09______________________________________________________________________ $2.00 ________
10______________________________________________________________________ $2.00 ________
11______________________________________________________________________ $2.00 ________
12______________________________________________________________________ $2.00 ________
13______________________________________________________________________ $2.00 ________
14______________________________________________________________________ $2.00 ________
15______________________________________________________________________ $2.00 ________
16______________________________________________________________________ $2.00 ________
17______________________________________________________________________ $2.00 ________
18______________________________________________________________________ $2.00 ________
19______________________________________________________________________ $2.00 ________
20______________________________________________________________________ $2.00 ________
21______________________________________________________________________ $2.00 ________
22______________________________________________________________________ $2.00 ________
23______________________________________________________________________ $2.00 ________
24______________________________________________________________________ $2.00 ________
25______________________________________________________________________ $2.00 ________

... (if more, just reprint order form) ...................................... Total Order/Payment Amount: $

____________________________________________________________________
NOTE: You may PRINT OUT, then FILL IN & MAIL IN this Order Form.

NOTE: Customer name & address Required ONLY for Return Mailings (diskettes or pictures).

NOTE: Picture Scan will choose scan size, file size & sending method if not specified by you.

NOTE: Picture Scan uses 3.5", 1.44mb capacity diskettes for return scan mailings.

Thank you for your order!

Customer Comments: