Fax Back Order Form

To order Play Attention, complete the information below and fax completed form to 866.506.2756. Or mail forms with certified check to Unique Logic &
Technology, PO Box 2147, Skyland, NC 28776. Be sure to include your Visa or MasterCard number and expiration date or have your card
ready and phone (800) 788.6786. Personal checks may delay shipment by 10 business days. Please allow 10 days for delivery. Overnight delivery is
available upon request for an additional charge.
Bill To:
Name:
Address 1:
Address 2:
City: State: Zip:
Email:
Phone: ( )
Ship To:
Name:
Address 1:
Address 2:
City: State: Zip:
Email:
Phone: ( )
Qty. Price Each Total Method of Payment
Start
Here
Play Attention Learning System(s)
(circle one: PC Version Mac Version)
Operating System
(circle one: PC: Windows / 2000 / XP/ Vista)
N/A Visa MasterCard
Credit Card Information:
Card Number:

Exp. Date:
Name on Card:
Signature:
Please allow 10 days for delivery. Overnight delivery is
available by request for an additional charge.
Please call (800) 788-6786 to conrmreceipt of
your order.
Play Attention Software Upgrade v5.4 $150.00 $150.00
Premier Suite (6 add-on games) $358.00



Shipping/Handling USPS $5.50 $5.50
Total