Use
this secure form to subscribe to
Neurotech Business Report
You are connected to a secure
server using up to 128-bit encryption.
Neurotech
Reports accepts the following forms of payment

|
Your
E-mail Address:
Where we will send you account
information, and receipt. |
|
Contact
Person for this
order: |
|
Your
Domain Name: |
|
Select
Neurotech Business Report Subscription:
Select Desired Subscription:
IMPORTANT
NOTES:
- Individual
on-line subscriptions are for one person/email address
only. No sharing of password allowed.
- For
multiple readers at one location, a site license for
up to 15 readers is available for $1,495 US per year.
You will be entitled to multiple account ids/passwords.
- You
may cancel your subscription anytime within the 30 days
for a full refund or any time for a refund of the unused
portion..
- Payment
must be in US funds; checks must be written on a US
bank instrument.
- Entire
contents of print and on-line editions of Neurotech
Business Report, Copyright © 2001, Neurotech Reports,
all rights reserved. No portion of this site or the
publication may be reproduced without written consent
of Neurotech Reports
|
Billing/Payment Information
|
First
Name
(on
credit card): |
|
Last
Name
(on credit card): |
|
Company
Name (if
applicable): |
|
Phone
number
where
you receive card statement:
|
|
Daytime
Phone number
(if
different): |
|
Billing
Address
(where
you get your credit card statement): |
|
|
Billing
City:
|
|
Billing
State: |
|
Billing
Zipcode (+4 if known): |
|
Billing
Country: |
|
Select
Credit Card Type:
|
|
Credit
Card Number (with spaces
or dashes as on your card): |
|
Credit
Card Expiration (00/00):
|
|
Security
Code: for
Visa and American Express you MUST include your security
code. On Amex it is on the front as 4 printed digits above
the last of your card number. On Visa, it is on the back,
and is the final 3 numbers (see image, at right).
We
will contact you for these numbers if not included here.
|
|
For
all credit cards, please provide the card provider's
phone number (usually a toll-free number on reverse
of your card). Note: if this is a debit-card from your bank
(which is not a credit card), please indicate bank name
or phone: |
|
CREDIT
CARDS NOTE: We ask for this credit card security information
because while you are protected from online fraudulent use
of your credit card, we are not. If we provide services
for a customer based on fraudulent credit card use, we have
no recourse and will be charged by the credit card company
for the full amount. |
Comments
or Special Instructions: |
|
THIS IS A SECURE, ENCRYPTED
FORM
All credit card information is verified to prevent fraud.
Please press the "submit" button only once. A confirmation
screen will appear. All credit card payments are processed
"offline" for additional security (this form does not
use automated payment processing).
Thank you for choosing Neotrope Software.
NOTE: Your credit card statement will show billing by
Micro Publishing Press, Inc., and not Neurotech Business
Report.
|