Welcome to our unsecure order form
*= "optional field"

I feel comfortable sending the necessary information online
I will fax my credit card information to you at (775)-719-7990
I will email you my credit card information split into two separate emails

First Name:
Last Name:
Email:
Confirm Email:
(this is where we will send your login info.)
*Company:
Address:
City:
State:
Zip:
Country:
Phone:
*Credit
Card:		 Visa
MasterCard/EuroCard
American Express
Optima
Diners Club/Carte Blanche
*Card #:
*Expiry
Date:

Your credit card will be billed in the amount of U.S. $97, in purchase of The Neo-Tech Discovery (if your order before June 15, you will also receive God Man: Our Final Evolution). All orders are processed within 48 hours of the time in which we receive your credit card information. Please email or fax us your credit card information immediately, if you indicated above that you would do so. Please note that "Verza, Inc." will appear on your next billing statement.