Existence-ok� Industries�

Please make a choice on what you want:-

Please provide your contact information:

Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code 
Country
Work Phone  
Home Phone  
FAX  
E-mail
Website

Please identify and describe yourself:

Date of Birth
Sex Male Female
Height
Weight
ID Number
Hair Color
Eye Color

Enter the date of today :

-- dd/mm/yy

Enter the present time :

-- hh:mm:ss am/pm

Choose one of the following IT options:


Select any of the following Information Systems options that apply:

Domain Name
Website Designing
E-mail Creation
E-mail Maintenance
Hosting Applications
Hosting Services
Search Engine
Website Management
Consultancy

Select any of the following Communication Systems options that apply:

Wireless Accessories
Mobile Accessories
Internet Accessories
Computer Accessories
Media Accessories
Consultancy

Would you like any other thing ?

Yes No

Type out what you want to add ?


How much or many do you want. ?


Please provide the following ordering information:

QTYDESCRIPTION

BILLING
Purchase Order #
Account Name

SHIPPING
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code 
Country

Please provide the following product information:

Product Name
Model
Version Number
Operating System

How would you rate your opinion of existence-ok.com. ?

1 2 3 4 5


Author: Oko Offoboche
Copyright � 1999 Existence-ok Industries�. All rights reserved.