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
Number ___________________________________________
Expires _____/_____
Name on card _________________________________________
Security Code ________
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