Gameport Secure Ordering Form

This form is for ordering by mail.
Please complete and print this form and send it together with a check to the address below:
MS Electronics - Gameport
10661 Rene St.
Lenexa, KS 66215

Product Description

Product:		Py and Gity 2
Platform:		PCGames
Price:		US $19.05 includes 4.10 for UPS shipping
		(US $19.05 includes 4.10 for shipping shipping (UPS Ground) to Canada)
		(US $19.05 includes 4.10 for shipping to locations outside of North America)

Personal Information

First Name:
Middle Initial:
Last Name:
Street Address:
Apt/Suite #:
City:
State (U.S. only):
Province (Canada only):
Country:
Zip/Postal Code:
Work Phone:	US and Canada xxx-xxx-xxxx
Home Phone:	US and Canada xxx-xxx-xxxx
E-mail Address:

Register Software

Upon credit card approval, your credit card will be charged the amount of US $14.95 PLUS shipping costs, your order will be processed and details of this purchase will be sent promptly to the E-mail address above.

Please make sure that your E-mail address is correct!

Your product will be shipped to you in the next few days.