Order:
To order Intelliform, please complete the information below, print and email to sales@intelliform.net 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):
monthly 1 @ 54/mo. 2 @ 70/mo. 3 @ 80/mo. 4 @ 90/mo. 5 @ 100/mo. 6 + call
annual 1 @ 49/mo. 2 @ 65/mo. 3 @ 75/mo. 4 @ 85/mo. 5 @ 95/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!