Active To-Do List Order Form

Name:     ______________________________________

Address:  ______________________________________

City:     ________________________    State:  __

Zip Code: __________     Country: ______________

Phone: _________________________________________

E-mail address: ________________________________

How did you obtain Active To-Do List?
________________________________________________

Any improvements that you would like to see?
________________________________________________
________________________________________________

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Active To-Do List License: (choose one)     ____
    New License               $19.95
    Upgrade                    $9.95

Program on CD: (Optional)                 + ____
  Within United States           $10
  Outside United States          $15

Total Payment Enclosed:                   = ____

If paying by check, please make it payable to
"Beiley Software Inc.".  US funds only please.
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Please send payment to:

  Beiley Software Inc.
  1161 North Dustin Lane
  Chandler, AZ 85226

  E-mail:  www.beiley.com/contact.html
  Phone:   (480) 705-0129
  FAX:     (480) 705-9219

If paying by credit card please fill in the following:

Card Number:________________________________________

Expiration Date (mm/yy):___/___

CVV2:____

Cardholder's Signature:______________________________