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Order for Tellurian tftpdNT

Ship To (name)

(email address)
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.............................................		 Licensee's name
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Fax receipt to
+......(......)......-.............		 Address ..................................................

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Product Details
(tick one)
Source - $AU6,000
OEM - $AU3,000
Enterprise - $AU1,500
Single machine - $AU100
Payment Details
(Delete section which does not apply)
Credit Card Payment
Card type
(visa,amex,mastercard)		 ...................... Card number .. .. .. .. - .. .. .. .. - .. .. .. .. - .. .. .. ..
Card expiry date ....................... Card holder's name ..................................................

Amount of payment
$AU............
Signature
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Cheque Payment A cheque for $AU............ is enclosed with this order.