BrainWave Order Form

Name:    ________________________________________________

Email:   ________________________________________________

Address: ________________________________________________

	 ________________________________________________
 
	 ________________________________________________


LICENSE TYPE (tick one)

Single User  (US$75)   ____   Student      (US$35)   ____  

Twenty User  (US$500)  ____   Site License (US$750)  ____

FORM OF PAYMENT (tick one)
 
___ Cheque or Money Order (made out to UniQuest Limited)
___ Invoice 
___ Visa 
___ Mastercard
___ BankCard 

CREDIT CARD DETAILS

Full name on card      ____________________________

Card #		       ____________________________

Expiration Date	       _____

Please debit my credit card for US$_______________

Signature _________________________________________

INVOICE ADDRESS

___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
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Send completed order form with enclosed payment to:

General enquiries can be directed to: brainwav@psy.uq.edu.au