Windows 9-1-1 Registration/Invoice Form
LD Technologies, Inc., 6705 Hidden Lake, Brecksville, OH 44141  USA


              Name: ______________________ Title: ______________

           Company: ____________________________________________

           Address: ____________________________________________

  City, State, Zip: ____________________________________________

           Country: ____________________________________________

             Phone: ____________________ FAX: __________________

    E-mail address: ____________________________________________


                            Quantity     Unit Price       Amount
        1-user license:       ____         $5.00          ______
       10-user license:       ____        $25.00          ______
      100-user license:       ____        $50.00          ______
unlimited-user license:       ____       $100.00          ______

                                        Sub total         ______
                  Ohio residents add 7% sales tax         ______
                                    Total payment         ______

    Payment Method: [ ] Check, payable to LD Technologies, Inc.
                    [ ] MasterCard [ ] VISA [ ] AMEX [ ] Discover

Credit Card Number: ____________________________________________

   Expiration Date: ____________________________________________

      Name On Card: ____________________________________________

   Billing Address: ____________________________________________

                    ____________________________________________



 Registration Name: ____________________________________________
                    (Should match the one on Register screen)

 Registration Code: ____________________________________________
                    (To be provided by us)

 How would you like to receive Registration Code:
                    [ ] E-Mail [ ] FAX [ ] Postal Mail