BLUEBELL DATA MAIL/FAX ORDER FORM

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Print & Mail to:

Unit 12 BSS House
Cheney Manor Trading Est
Swindon
SN2 2PJ

Please make cheques & Postal Orders 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__________________________________________Important!

Product: The Lay betting System


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

Name on Card________________________________________________

Credit Card No. _________________________________Exp Date __________

Valid From Date __________

3 Digits on back of card __________ Usually 4 followed by 3, its the last 3 that we need.

Issue Number (switch): __________________

Qty ______    The Lay betting System@ £39.99

Sub Total _£39.99

Carriage________  £1.00 UK - Only (if you want it delivered on CD rom)

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.

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