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  1. InterQuick Print and Fax Order Form
  2.  
  3. Deerfield.com
  4. 4241 Old U.S. 27 South
  5. P.O. Box 851 
  6. Gaylord, MI  49735  U.S.A.
  7. Voice: +1 517.732.8856
  8. FAX:   +1 517.731.2642
  9.  
  10. Please complete, print and fax this order form to +1 517.731.2642
  11. Please fax only page 1.
  12.  
  13. InterQuick Version 2.x
  14.  
  15. Quantity:    
  16. Unit Price:  
  17. Sub Total:   
  18. Sales Tax:   
  19. (Sales Tax is 6% for Michigan Customers Only)
  20. Grand Total: 
  21.  
  22. NOTE: Please complete the following Customer & Credit Card
  23. Information, ensuring that all information is completed
  24. accurately.  The accuracy of your email address is extremely
  25. important as your registration details are sent to you via email.
  26.  
  27. First Name:                
  28. Last Name:                 
  29. Company:                   
  30. Name to appear on license: 
  31. Address1:                  
  32. Address2:                  
  33. City/Town:                 
  34. State/Region:              
  35. Zip/Postal Code:           
  36. Country:                   
  37. Phone:                     
  38. Fax:                       
  39. Email Address:             
  40.  
  41. Credit Card Type:        
  42. Note:  We accept Mastercard, Visa, American Express and Discover
  43. Credit Card Number:      
  44. Expiration Date (MO/YR): 
  45. Name on Credit Card:     
  46.  
  47. Alternative Payment Method: 
  48.  
  49. NOTE: If you wish to place your order and utilize an alternative
  50. payment method, please leave the credit card details blank and
  51. enter Check/Money Order, Purchase Order or Telegraphic Transfer.
  52. Please be advised that you will not be issued registration details
  53. until payment has been received.  An additional $25 must be
  54. added for Telegraphic Transfers.
  55.  
  56. InterQuick includes free email technical support and free
  57. upgrades for a period of one year from the date of purchase.
  58.  
  59. To purchase additional tech support and upgrade protection,
  60. please call Deerfield.com at +1 517.732.8856.
  61.