Individual Teacher Post/Fax Order Form

• By post: Print out the form below, complete it and send it to: URBrainy, P.O.Box 7533, Weymouth, UK, DT4 4FP
• By fax: Print out the form below, complete it and fax it to: 01273 78 5549

Please subscribe the teacher/class to URBrainy for one year for £48

Your name________________________________

Job Title/ Class_________________________

School name__________________________________________________________

School address________________________________________________________

_________________________________________ Post code___________________

School phone number__________________________________________________

School email address___________________________________________________

Password you wish to use for this account__________________________________

Please select one method of payment

• Cheque enclosed (please tick)___________
• Please invoice against this school order number______________
• Use this credit card number______________________________ Exp date__________3 figure security code_______ Name of cardholder_____________________________

  Address of cardholder____________________________________________________