Certification Zone Order Form

Please enter the Username and Password you wish to identify your account.
You will need to save this information in order to place future orders.

Username _______________________
Password _______________________

Customer Information:

First Name _______________________
Last Name _______________________
Company _______________________
Address Ln 1 _______________________
Address Ln 2 _______________________
City _______________________
State _______________________
Province / Territory _______________________
Zip _______________________
Country _______________________
Phone _______________________
Fax _______________________
Email _______________________

Name on Credit Card _______________________
Card Type _______________________
Card Number _______________________
Card Expiration (MMYY) _______________________

Choose One Below:

________ 3 month Subscription $67.00
________ 6 month Subscription $99.00
________ 12 month Subscription $179.00

Ways to order:

Fax this order form to 518-842-1843 with your credit card information.
Mail to address below include a check or money order for full amount.
Your check must be in US dollars, drawn on a US bank

Genium Publishing Corporation
1171 Riverfront Center
Amsterdam, NY 12010
Fax (518) 842-1843
(877)CCIE-NOW