PERSONAL INFORMATION  | |
| FIRST NAME: | __________________________________________ |
| LAST NAME: | __________________________________________ |
| COMPANY NAME: | __________________________________________ |
| STREET ADDRESS: | __________________________________________ |
| CITY: | __________________________________________ |
| STATE/PROVINCE: | _____ |
| ZIP/POSTAL CODE: | _____ |
| COUNTRY: | _____ |
| PHONE NUMBER: | __________________________________________ |
| FAX NUMBER: | __________________________________________ |
| E-MAIL ADDRESS: | __________________________________________ |
| ORDER INFORMATION | |
| PRODUCT: | |
| # OF PCS TO LICENSE: | _____ |
| MAINTENANCE? | |
| : | |
| PAYMENT INFORMATION We accept Visa, Mastercard and American Express and also accept Purchase Orders for orders in excess of $500. The following information is optional at this time but will expedite the ordering process once our sales representative contacts you.
| |
| NAME ON CARD: | __________________________________________ |
| TYPE OF CREDIT CARD: | __________________________________________ |
| CARD NUMBER: | __________________________________________ |
| CARD SECURITY CODE: (3 or 4 digit code on card) | _____________ |
| VALID FROM DATE: | _____/_____/_________ |
| EXPIRATION DATE: | _____/_____/_________ |
| PURCHASE ORDER NUMBER: | __________________________________________ |
| SIGNATURE: | __________________________________________ |