Split Order Form

WELCOME TO THE DEMO STORE!
THIS IS FOR DEMONSTRATION PURPOSES ONLY. This is a demonstration of NiftyPay's Split-Form technology. The customer's name, address, and email address are requested on the merchant's site. Account information is not obtained until the customer has reached the payment secure server.

	PRODUCT DESCRIPTION		PRICE

	Octane Laptop XL34			$2,275.95
	Intel 233 MHz Pentium 4.1GB Hard Drive 4MB Video RAM Internal 20X CD-ROM		64MB EDO RAM TV-Out Port 13.3" TFT/DSTN 16-bit Stereo Sound
	Select to Order \| Quantity:

	PRODUCT DESCRIPTION		PRICE

	THX Workstation			$2,385.95
	Intel Pentium 32MB Sychronous DRAM 3.2GB Hard Drive QWE 3D Grahics Card 2MB SDRAM		17" CRT .28dp Monitor 33.6 Fax Modem 16-bit PCI Sound Card Enhanced Software Collection titles
	Select to Order \| CPU Speed: Increase Monitor to 19 inch (Add $300.00) Add 32 MB RAM (64 MB total) (Add $40.00)

	PRODUCT DESCRIPTION		PRICE

	Stellar EXC+ Server			$4,102.00
	Intel 333 MHz Pentium II Intel Triton 440FX Chipset 9.4GB SCSI Hard Disk 30X IDE CD-ROM 128MB EDO RAM		17" Flat Screen .28NI Monitor 240W Stereo Speakers MS Windows NT/Office 56K Fax/Modem w/Voice 3-Year On-Site Warranty
	Select to Order \| Case Color: 56k Sportster Modem (Add $65.00) 400 MHz Processor (Add $249.95)

GENERAL INFORMATION

First Name:	Last Name:
Address:
City:	State: Zip:
Country:
Phone Number:
E-Mail Address: