Order Form
(see mailing/fax instructions below)

Please print your practice name and address as you would like it to appear on your reports.

Practice Name:____________________________________________________________

Your Name:_______________________________________________________________

Address:_________________________________________________________________

             _________________________________________________________________

City:________________________________ State:________ Zip:____________________

Office Phone: (_______)____________________ Fax: (_______)___________________

E-mail ____________________________________________
 

Payment by:

Check          Check number _________

Credit Card

___ Visa ___ MasterCard ___ American Express
 

Number ___________________________________________   Expires _____/_____


Name on card _________________________________________  Security Code ________
 

Cardholders information (where your bill is sent), if different from above...

Street _______________________________________________________________________

Phone (_______)_________________________________  Zip Code ________________
 

       
     
___

Purchase price

$497.00

~OR~
___ Monthly Subscription
$27.00

Only $27 per month (minimum 6 months). The subscription is automatically billed to your credit card each month for as long as you want to use the software (includes unlimited support and updates). 1/2 of your subscription is applied to the full purchase price at any time up to $250.

 

Additional Options

 
___ Internet Entry - monthly (no setup fee!)

$22.00

Only $22 per month (minimum 6 months). The subscription is automatically billed to your credit card each month for as long as you want to use the software (includes unlimited support and updates).
___ Multi-User option allows up to 5 simultaneous users on your office network.

FREE

All prices include shipping and handling within the continental US.
  New York State residents add sales tax

___________

  If you are located within New York or North Carolina, please enter the County you are located in below:  
  __________________________________________  
     
Total.......

___________

Please print this form and mail or fax this completed form to:

Greene Software
Systems Survey Maestro
121 Summit Hill Rd
Hendersonville, NC 28791
Phone: 585-924-4456    
Fax: 585-486-1947
sales@surveymaestro.com
http://www.surveymaestro.com