LAN-Projekt
       Placheho 17     tel: +420 377 993 114
301 26 PLZEN           fax: +420 377 993 155
       Czech Republic

WinProxy Upgrade - Order Form
=============================

Your present serial number:__________________________

Your present key:____________________________________

Select type of your upgrade:

[ ] from 5 to 10-user    (120 USD)
[ ] from 5 to unlimited  (240 USD)    
[ ] from 10 to unlimited (120 USD)    

Select option of payment for WinProxy:

[ ] Credit Card - we can accept VISA or Eurocard / MasterCard only
[ ] Bank Transfer to our account "CSOB - CEKO CZ PP PLZ 278871003"
     (a transfer fee is paid by sender)
[ ] Cheque (attach it to this form and send it by post, please)

Concerning my person / company

 Name: ______________________________________ 

 Company: ___________________________________

 VAT Number (*): ____________________________

 Address: ___________________________________

 City & Postal Code: ________________________

 Country: ___________________________________

 Telephone: _________________________________

 Fax: _______________________________________

 E-mail: ____________________________________


In case of payment by credit card please fill in the following:

 Card type (other cards are not supported):

  [ ] Visa Eurocard            [ ] MasterCard

 Card number: ________________________________

 CVC2 / CVV2: __________________________________  
 (The last three-digit No. on the back side of your card)

 Card holder: ________________________________

 Valid until: ________________________________


(*) Unless you provide a valid VAT ID a 19% tax will be added
    to the price (applied to EU customers only)


I promise I won't use my old serial number after upgrading.

Date:__/__/__     Signed:____________________ (required)

Additional comments: