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 Monthly Charge (Circle One):
1 @ $39.95 /mo. 2 @ $54.95 /mo. 3 @ $64.95 /mo. 4 @ $74.95 /mo. 5 @ $84.95 /mo.
Payment (Circle One): Visa MasterCard
Card #: ____________ ____________ ____________ ____________ Exp: ______ / ______
Authorized Signature: ______________________________________________________________
Please print name of Authorized Signature: ____________________________________________
The first 30 days will be billed upon receipt of this order form. The subsequent 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.
Intelliform will be sent by Priority U.S. Mail. Please allow one week for delivery.
Thank you for your order!