Prodecom 4.1 -- Site Registration Form

1. Company information (please PRINT):

Company Name: ___________________________________________________
Site Address:____________________________________________________
City: ___________________ State/Province: _______________
Country: ____________________________________ ZIP/PC: ___________
Phone number: (___)______________ Date (MM/DD/YY): ____/____/____
Authorized representative: ______________________________________
Email address:___________________________________________________

2. Shipping and Handling (check one):

__ Email registration information to email address in (1) above.
__ Mail 3.5'' DS/HD disks to mailing address in (1) above
   (US/Canada: $5.00 per disk, outside US/Canada: $12.00 per disk)

3. Payment and fees:

Fees are in US dollars, please do not send cash. Checks and money 
orders must be made payable to Antoine Delle Donne. Select form of 
payment (check one):

__ Enclosed check or money order
__ Credit card payment: ___ VISA   ___ MasterCard    
   Name on card: _____________________________
   Card Number: ______________________________
   Expiration Date (MM/YY): _____/_____
   Signature (required if form is faxed/mailed): _________________

4. Pricing for the use of Prodecom 4.0 or newer, per site computer 
   (Please write for pricing on quantities over 99 computers):

__  1st computer at $30:                               = $ 29.00
__  2nd to 24th computer at $19 each: ...... ____ x 20 = $______
__ 25th to 99th computer at $16 each: ...... ____ x 17 = $______
__ Total US Shipping and Handling ...................... $______
__ Total Non US Shipping and Handling .................. $______
__ Canadian companies add 7% Goods and Service tax...... $______
__ Qu‚bec comoanies add 6.5% sales tax.................. $______
Total:.................................................. $______

5. Mail this form together with payment to:

   Antoine Delle Donne
   Prodecom Registration
   71a 2nd Avenue
   Ile Perrot, Qu‚bec
   Canada J7V 4Z3

   If credit card payment was selected, this form may be faxed to 
   514-453-1727 (Qu‚bec, Canada) or emailed to 25157@ican.net

Prodecom Home Page
http://www.geocities.com/WallStreet/1138/