Intelliform

Simple Solution  Powerful Results

 

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Order:

To order Intelliform, please complete the information below, print and fax to us at 412-967-0544. An authorized signature is required. 

Order Date:

Contact Name:

Company:

Street (Line 1):

Street (Line 2):

City, St., Zip:

Phone:                                   

Fax:

E-Mail:

# of Licenses and pricing (Circle One):

1 @ 49/mo.    2 @ 64/mo.    3 @ 75 /mo.    4 @ 85 /mo.    5 @ 95 /mo.    6 + call

annual   1 @ 44/mo.    2 @ 59/mo.    3 @ 69/mo.    4 @ 79/mo.    5 @ 89/mo.    6 + call

Payment (Circle One):         Visa              MasterCard   

Card #: ____________   ____________   ____________   ____________    Exp: ______ / ______

Authorized Signature: ______________________________________________________________

Please print name of Authorized Signature: ____________________________________________

The monthly charge will be billed on the first of each month. Intelliform may be cancelled at any time. Cancellations will be effective the day they are received by Intelliform. Partial months are not prorated.

 

Thank you for your order!