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Text File  |  1990-02-24  |  6KB  |  78 lines
  1.                      dCOM Site-License Request Form
  2. ┌──────────────────────────────────────────────────────────────────────┐
  3. │      Make checks payable to:                          Page 1 of 2    │
  4. │                                                                      │
  5. │                         DAC Micro Systems                            │
  6. │                         40941 176th St E                             │
  7. │                         Lancaster, CA  93535                         │
  8. │                         Voice: 805/264-1700                          │
  9. │                         Data:  805/264-1219                          │
  10. │                                                                      │
  11. │             5 to  9 copy license    ___ x $29.00 each  $_____        │
  12. │            10 to 49 copy license    ___ x $25.00 each  $_____        │
  13. │            50 to 99 copy license    ___ x $21.00 each  $_____        │
  14. │                100+ copy license    ___ x $19.00 each  $_____        │
  15. │                                                                      │
  16. │                                           Subtotal     $_____        │
  17. │                                                                      │
  18. │      California residents please add 6.5% sales tax.   $_____        │
  19. │                                                                      │
  20. │      Shipping and handling - inside the United States   $3.50        │
  21. │                                                         - or -       │
  22. │                            - overseas                   $5.00        │
  23. │                                                                      │
  24. │      Credit Card orders add 3% surcharge               $_____        │
  25. │                                                                      │
  26. │                                                Total   $_____        │
  27. │                                                                      │
  28. │      Diskette type (check or circle one):  [ ] 5.25"  [ ] 3.5"       │
  29. │                                                                      │
  30. │      Processor type (check or circle one):  [ ] IBM   [ ] Z100       │
  31. │                                                                      │
  32. │      Checks & Money Orders must be drawn on US banks in US funds     │
  33. │                                                                      │
  34. │      Payment (check or circle one):                                  │
  35. │                                                                      │
  36. │      [ ] Check  [ ] Money Order  [ ] Visa  [ ] MasterCard            │
  37. │                                                                      │
  38. │      Credit Card #___________________________________________        │
  39. │                                                                      │
  40. │      Expiration Date _______  Signature _____________________        │
  41. │                                                                      │
  42. │      Credit Card Orders may be placed by phone:  805/264-1700        │
  43. │                                                                      │
  44. └──────────────────────────────────────────────────────────────────────┘
  45.  
  46.     dCOM Version ____                             Site License Form
  47. ┌──────────────────────────────────────────────────────────────────────┐
  48. │                                                       Page 2 of 2    │
  49. │                                                                      │
  50. │       Name_______________________________________________________    │
  51. │                                                                      │
  52. │    Company_______________________________________________________    │
  53. │                                                                      │
  54. │    Address_______________________________________________________    │
  55. │                                                                      │
  56. │           _______________________________________________________    │
  57. │                                                                      │
  58. │      Phone_________________________  Bus.________________________    │
  59. │                                                                      │
  60. │   Where did you obtain dCOM?                                         │
  61. │                                                                      │
  62. │           _______________________________________________________    │
  63. │                                                                      │
  64. │   Comments_______________________________________________________    │
  65. │                                                                      │
  66. │           _______________________________________________________    │
  67. │                                                                      │
  68. │           _______________________________________________________    │
  69. │                                                                      │
  70. │           _______________________________________________________    │
  71. │                                                                      │
  72. │           _______________________________________________________    │
  73. │                                                                      │
  74. │           _______________________________________________________    │
  75. │                                                                      │
  76. │                                                                      │
  77. └──────────────────────────────────────────────────────────────────────┘
  78.