Imaja PicScan: Order Form

Print this page, fill in the blanks, and mail or fax to Imaja. Make check or money order payable to Imaja. Order online with MasterCard/VISA.

 Check or money order enclosed (US$) 

Name __________________________________________________________________________________

Company _______________________________________________________________________________

Address _______________________________________________________________________________

City/State/Zip ________________________________________________________________________

Country _______________________________________________________________________________

Phone (Required) _____________________________________Fax______________________________

E-mail _________________________________________Mac Model/System_______________________