Order Form
Your Name:_________________________________________________________
Email Address:______________________________________________________
Phone:________________________
Office Name as you would like it to appear within the software you are ordering:
___________________________________________________________________
| Shipping Address | Billing Address |
| Company
|
Company
|
| Address Line 1
|
Address Line 1
|
| Address Line 2
|
Address Line 2
|
| City / State / Zip
|
City / State / Zip
|
| Attention:
|
Attention:
|
| ITEM NO | PRODUCT | QUANTITY | UNIT PRICE | AMOUNT | |
| 1 |
|
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| 2 |
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| 3 |
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| 4 |
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| SUBTOTAL | |||||
| Colorado locations add 3% City of Aurora add 3.75% (6.75 total) |
TAX | ||||
| 0.00 | SHIPPING | ||||
| TOTAL |
| Payment Type (check one) |
Method (check one) |
Payment Info |
| ___ Credit Card | ___ VISA ___ M/C ___ AmEx ___ Discover |
Card Number _______________________ Expiration (mm/yy): _________________ |
| ___ Purchase Order | ___ Attached ___ To follow |
P.O. Number _______________________ |
| ___ Check / Money Order | ___ Enclosed ___ Remit upon receipt |
This payment option not available to government agencies |
Signature authorizing payment: __________________________________Date:____________
Special Instructions:
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Mail or fax this completed form to the address / fax number at the top of this form.
Back to the Order Info page.
Copyright © 1999 Paul Charbeneau Enterprises