3200 Executive Park Circle
Mobile, Alabama 36606
FAX Order Form
(251) 470-1981

(click here for order form in Adobe .PDF format)
Name: ____________________________________________________________________
Billing Information
Company (if applicable): ____________________________________________________________________
Address: ____________________________________________________________________
City, State/Province: ____________________________________________________________________
Zip/Postal Code, Country: ____________________________________________________________________
Shipping Information (if different from Billing Information)
Company (if applicable): ____________________________________________________________________
Address: ____________________________________________________________________
City, State/Province: ____________________________________________________________________
Zip/Postal Code, Country: ____________________________________________________________________
This address is:
 Commercial ______ Residential ______ (check one)
Phone: ____________________________________________________________________
E-mail: ____________________________________________________________________
Fax: ____________________________________________________________________
How did you hear about this product? ____________________________________________________________________
Chapura Products Quantity Unit Price Total Price
Palm OS      
TurboPasswords™ ________ $29.95 ________
Pocket Favorites™ ________ $9.95 ________
KeySuite™ ________ $69.95 ________
PocketMirror® Professional (U.S. Version) ________ $49.95 ________
PocketMirror® Professional (Upgrade) ________ $24.95 ________
PocketMirror® Standard (U.S. Version) ________ $29.95 ________
PocketMirror® Standard (Upgrade) ________ $19.95 ________
Call Log+™ for Treo 700p or Treo 650 ________ $19.95 ________
PocketCopy™ ________ $24.95 ________
Windows Mobile / Pocket PC      
PocketMirror® Professional for Windows Mobile (U.S. Version) ________ $49.95 ________
PocketCopy™ ________ $19.95 ________
Shipping and Handling
UPS Ground $7.95 (U.S. Orders only)
FedEx Overnight $15.00 (U.S. Orders only)
International USPS Global Priority $12.00
(does not include additional country and/or duty taxes)
International FedEx (See table below)
 ________  
 ________
Total ________ ________ ________
Payment Information
Credit Card Type
(circle one)
VISA MasterCard AMEX Discover
Full Name on Card: ____________________________________________________________________
Credit Card Number: _______________________________________________Exp Date: ____________
Signature: ____________________________________________________________________







International FedEx Rates (includes Shipping, Handling, VAT and Duty )
Algeria
 $50 Costa Rica $38 Hungary $50 Peru $38
Argentina $38 Croatia $50 Iceland $50 Philippines $31
Australia $31 Czech Republic $50 India $38 Poland $50
Austria $30 Denmark $30 Indonesia $31 Portugal $30
Bahamas $28 Dominican Rep. $28 Ireland $28 Russia $50
Barbados $28 Ecuador $38 Israel $31 Saudi Arabia $50
Belgium $28 Egypt $31 Italy $28 Singapore $28
Belize $38 El Salvador $38 Jamaica $28 South Africa $50
Bermuda $28 England (U.K.) $28 Japan $28 South Korea $31
Bolivia $38 Ethiopia $50 Kenya $50 Spain $30
Brazil $38 Finland $38 Mexico $25 Sweden $30
Bulgaria $50 France $28 Nepal $38 Switzerland $30
Cambodia $38 Germany $28 Netherlands $28 Taiwan $28
Canada $25 Greece $30 New Zealand $31 Turkey $31
Cayman Is. $28 Grenada $28 Nicaragua $38 Venezuela $38
Chile $38 Guam $38 Nigeria $50 Vietnam $31
China $30 Haiti $28 Norway $28 Virgin Islands $28
Columbia $38 Hong Kong $28 Panama $38 Zimbabwe $50

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