Associated Quality Consultants, Inc.
PO Box 1412
Herndon VA 20172-1412
 Fax: (703) 834-8209

Make Your Payments by Visa, Mastercard or American Express

By submitting this form you authorize Associated Quality Consultants, Inc. 
of Reston, VA, (Corporate Tax ID# 54-1858378) to make a charge on your
credit card account for the amount shown below for the product(s) you're
purchasing. 

!! IMPORTANT INFORMATION !!
Be sure to complete
ALL Requested Information

PLEASE PRINT!

Your Full Name: ____________________________________________
 
Address: ___________________________________________________

City/State/Zipcode: ________________________________________

Area Code/Phone Number: ____________________________________

E-mail Address: ____________________________________________


Pay By Credit Card

Credit Card Type (VISA, MC or AMEX): _______________________
   
Card Number: _______________________________________________

Expiration Date (MM/YY): ___________________________________

Name on Card: ______________________________________________

Amount of Charge: $_________________________________________

Signature of Cardholder: ___________________________________


Purchase Item(s): (Check All That Apply)

   ______  Website Hosting (annual payment) @ $320/year 	$320.00
   ______  Website Hosting (quarterly rate) @ $90/quarter	 $90.00
   ______  Website Hosting (monthly rate) @ $30/month	 	 $30.00
   ______  Mailing List Hosting ($10/month, 3-month min.)	 $30.00
   ______  Domain Registration Support				 $20.00
   ______  Portable Email Address (annual only)	 		 $30.00
   ______  Other Services (fill in the negotiated rate and 
	    identify product(s) in the "comments" section below) $_____

Prices listed are in US dollars (US$). 

Comments: __________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________



By entering the amount and submitting this document, you agree
to allow Associated Quality Consultants, Inc. to make a charge on your
account for the above product(s) and amount.

Please fax the completed form to us at one of the fax numbers above or
email it as an email attachment, if you have that capability. 

You may also US Mail this completed form to us at:

	AQC
	PO Box 1412
	Herndon VA 20172-1412

Thank you for your support!