Go-Lotto Visa / MC Online Order Form

All Areas Must Be Filled In For Processing 1._____FULL NAME:
2._____VISA OR MC:
3._________CARD #:
4.____EXPIRE DATE:
5._________E-MAIL:
6._______ADDRESS:
7.__CITY STATE ZIP:
8.____TELEPHONE #:
-------------------------------------------------- N.Y. Residents add 9.50% Sales Tax --------------------------------------------------
$49.95 USD Software Downloaded on Internet
$53.45 USD Software Sent by Mail --- $49.95+$3.50 Shipping & Handling
9._______AMOUNT:
-------------------------------------------------- N.Y. Residents add 9.50% Sales Tax --------------------------------------------------
COMMENTS:

. . . . . . . . . . . . . . . Thank You For Shopping O'Falls Software . . . . . . . . . . .