M&A Computer Services Web Hosting
Order Form

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Customer Information:

Customer Name:
Address:
City: State: Zip: Telephone:
Fax:  E-mail:

Products/Services:

Qty. Description

We'll Contact you for Site Information after the order

We'll Contact you for Site Information after the order

Payment Options:

1) Pay by Credit Card

2) Check by Email (Fill out this form completely and simply press the submit order button at the end of the page.)

3) Check by Fax (Fill out this form completely, print and fax this form to M&A at: (937) 687-1328. NOTE:  Don't hit the submit button if you choose this option.)

4) Check By Mail (Fill out this form, print and mail to address below, along with your check or money order. NOTE:  Don't hit the submit button if you choose this option.)

NOTE: For Options 2 & 3 Only, Fill out the following Information: (We Only Ship or Perform Service after check clears, usually 10 business days)

Name On Check (If diffirent from above):
 NOTE:  Your bank will tell you any of this info if you can't find it.
Bank Name:
 Bank Address:
Federal Reserve Number (Fraction in upper right hand Corner): Check Number:
Routing Number (Always 9 Digits):
 Checking Account Number:

For Option 3, Please send the total amount to:

M&A Computer Services
2 N Church St
New Lebanon, OH 45345
Phone/Fax (937)687-1328

Thank You For Your Order!