My Game Business Software License Order Form

Sponsoring Distributor ID

NO SPONSOR CHANGES once the order is submitted

First Name	Last Name

Address

Company (If there is no company name, please leave the below field blank)

City	State	Zip

Country	E-mail

Phone Number (Example: USA 1-123-555-1212 UK 44-01632-960008 JAPAN 81-123-55-1212)

Required Information by the IRS

SSN (If outside the United States use "12345")	Federal Tax ID# (Numbers only, no dashes)

Date of Birth	Month:		Day:		Year:

Choose a Username	Choose a Password

*** Check the boxes of the products you would like to purchase from the list below ***

	GoldenFairway Golf Purchase Price: $99.00	Buy $99.00
	Redline Thunder: American Stock Car Purchase Price: $99.00	Buy $99.00
	Redline Thunder: Grand Prix Purchase Price: $99.00	Buy $99.00
	Liars Poker Purchase Price: $99.00	Buy $99.00
	Hometown Soccer Purchase Price: $99.00	Buy $99.00
	Hometown Bowling Purchase Price: $99.00	Buy $99.00
	Arcade Pack Get all 6 games for $495.00 Ad Manager is included at no additional charge.	Buy $495.00
	Ad Manager Purchase Price: $2000.00 [See Golf Ads] [See Racing Ads]	Buy $2000.00