Siborg Systems Inc
24 Combermere Crescent, Waterloo, Ontario N2L 5B1 Canada
Phone 519-888-9906
microtec@siborg.ca
Fax 519-725-9522
www.siborg.ca
MicroTec Order Page
Cardholder Information
Note: Enter the address to which your card statement is mailed. An incorrect address may result in your payment being rejected.
Fill-in and sign this Form and mail or Fax to the address above.
Cardholder Name
Company/Institution
Cardholder Address
City
Province/State
Postal/ZIP Code
Country
Phone Number
MicroTec version/type
Price Quoted
Email Address
Card Number
Expiry Date (mm/yy)
/
CVV2 number (the last three digits on the reverse side of your credit card)
Signature ___________________________
Date ________________________________