DataChem Software Order Form
Mail To: or FAX To: 508-366-5278
Datchem Software
Customer Name: _____________________________________________________________
Company: __________________________________________________________________
Ship To: Residence or Business address: Billing Address (for credit card):
________________________________________ ________________________________________
________________________________________ ________________________________________
________________________________________ ________________________________________
Daytime Phone: ___________________________ FAX: ___________________________________
Product License Price
1.____________________ Individual / Site _____________
2.____________________ Individual / Site _____________
Sales Tax (5% - MA Customers ONLY) _____________
Shipping & Handling _____________
(UPS Ground - $10, 2nd Day - $20, Next Day $25,
Canadian $35, International - Min. $55)
TOTAL _____________
EMAIL ADDRESS: (for shipping confirmation) ___________________________________________
Payment
You may pay by credit card, check or company purchase order. If paying by P.O., send or FAX a copy of the P.O. with this order. If paying by check, enclose check with this order. If paying by credit card fill out form below. You will receive a credit card receipt with the software.
Credit Card: VISA MasterCard Discover American Express
Card Number _____________________________________________ Expiration Date ____________
CID number __________ (AMEX card 4 digits printed on the front; other cards these are the last 3 digits found on the back on the signature line)
Name on Card _______________________________________
Signature ___________________________________________