ODBCExpress Order Form

Attention

          Kim Bastick

          Korbitec (Pty) Ltd                      Tel: +27 21 658 9700
          PO Box 243                              Fax: +27 21 658 9701
          Nuweland
          Cape Town
          7725
          South Africa


Customer Details

   First Name: _______________________________________________________

    Last Name: _______________________________________________________

      Company: _______________________________________________________
 
      Address: _______________________________________________________

         City: _______________________________________________________

  Postal Code: _______________________________________________________

      Country: _______________________________________________________

      Phone #: _______________________________________________________

        Fax #: _______________________________________________________

        Email: _________________________________________(PLEASE PRINT)
       

Product Details

  Note:

    Standard version: Source code NOT included
    Professional version: Source code included
    Ordering the latest version of any specific product includes all
    the previous versions of that product

  ODBCExpress Components:

  Quantity (Number of Developer Licenses)                   US$    ZAR

  [  ] Version 6.x Professional for Delphi 5-2006 ......... 399   2899
  [  ] Version 6.x Professional for C++Builder 5-6 ........ 399   2899
  [  ] Version 5.x Professional for Kylix 2-3 ............. 399   2899

                                                    Total: $____ R____

  (ZAR pricing is for South African customers only and includes VAT)

  The above pricing is valid as from 1 November 2007.

  Software is shipped via the Internet, at no additional cost.

  If necessary, please add complete details of the versions ordered in
  the comments section below.


Payment Details

                Card Type: VISA ___ MasterCard ___ AmEx ___ Diners ___

              Card Number: ___________________________________________

            Card Security: ___________________________________________

          Card Expiration: ___________________________________________

       Card Holder's Name: ___________________________________________

  Card Holder's Signature: ___________________________________________


                 Comments: ___________________________________________

                           ___________________________________________

                           ___________________________________________

                           ___________________________________________