StatPac For Windows Order Form

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Name_____________________________________________________________

Company Name_____________________________________________________

Shipping Address ___________________________________________________

__________________________________________________________________

City/State/Zip_______________________________________________________

Country ___________________________________________________________

Tel:_______________________________ Fax:_________________________

E-mail: ___________________________________________________________

Web site: _________________________________________________________

Basic Statistics Module ($695.00)	$ ___________
Web Survey Module ($495.00)	$ ___________
One-Year Technical Support/Maintenance Agreement ($150.00)	$ ___________
Special Combination Offer - All of the above ($995.00)	$ ___________

We send one User's Manual and CD with each order. If you would like extra manuals, add $40.00 per copy.

$ ___________

Advanced Statistics Module ($495.00)

$ ___________

Data Manager - Single User ($195.00)

$ ___________


Data Manager - Unlimited Users ($995.00)	$ ___________

Student Version of StatPac for Windows ($95.00)

$ ___________


Site License Agreement for 10 Users ($2,495.00)	$ ___________

Discount to not-for-profit organizations 15%

$ <_________>

Minnesota residents add 6.5% sales tax or provide your MN tax exempt number	$ ___________
Tax exempt # ______________________________

Non-US Shipping ($50.00)

$ ___________

Total

$ ___________

Type of Payment:

___ Check ___ Visa/MC ___ Discover ___ American Express

___ NET 30 - PO# __________________________________
(established accounts or with approval)

Name on Card ______________________________________________________

Card Number ____________________________________ Exp. Date _________

Signature __________________________________________________________

Mail this completed form and your check or credit card information to: StatPac Inc., 8609 Lyndale Ave. S. - 209A, Bloomington, MN 55420. For faster service, fax to (715) 442-2262. Your order will be shipped within 24 hours.