Order Form For
LCPStat_3
Please print this information
and order form using the "PRINT" button in your Internet
browser
Licensee Name:
________________Date of Order ______ ___
What is your operating system?
Windows 98 / ME / 2000 / XP or
Macintosh
Complete the following
information regarding your computer and printer:
Brand Name:
_________ _______
Model: __________________
_______________
Uninterrupted Power Supply
(UPS) Attached: yes no
Laser Printer: yes
no
Licensed
User
Please provide
information on the licensed user, company name, address, and phone
information.
Licensed user and Company
Name
________________________________________________________
_______________________________________________________
Address (Street or P. O. Box):
_____ ________________________
City / State / Zip Code:
_________ ___________________________
Office Phone: _________
____________________________________
Fax Number
(optional)_____________________________
Cost
for this LCPStat_3
Order
LCPStat_3
New User
Fee- $1,500.00 or
Current
User Upgrade Fee- $1,100.00
______ A Single payment
of $_____ .
______ 2 Payments of $____ each.
The above
cost includes one hour of customization and
orientation.
Enter Amount
__________
Technical
Support Options
Plan I:
Annual Maintenance Agreement a single payment for the year -
$288 yearly
Plan II: $2 per minute per
phone call. This will be billed on a credit card at the time of
the phone call
Note:
Orders include one year free technical
support.
Method
of Payment
______Check
______Credit card orders:
____VISA ____MasterCard ____American Express
Name as it appears on
credit card:
_________
________________________________
Account# _________
_______________
Expiration Date: _________
__________
Signature: _________
_______________
Date: _________
_______________
Ship to:
Name
________________________________________
Address (No P O Box if sending
UPS or FedEx):
________________________________________
City / State / Zip Code:
_________ __________
Office Phone: _________
______________________
Fax: _________
____________________________
E-Mail:
__________________________________
Please Fax All Pages of
This Order Form to 601 605-5812 and allow 1 week for
delivery
P.O. Box 2446,
Madison, MS 39130 (601) 946-0646 FAX (601) 605-5812