MedicWords Order Form

SpellingTech
PO Box 7462
Round Rock, TX 78683

Fax Number: 888-908-3524

 
Date ________________
How did you discover
MedicWords?

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Billing Information

Name ___________________________________________
Company ___________________________________________
Phone Number (______)______________________ Ext__________
Email Address ___________________________________________
Address ___________________________________________
City ___________________________________________
State ________________ Postal Code ________________
Country ________________
 

Shipping Information

Name ___________________________________________
Company ___________________________________________
Address ___________________________________________
City ___________________________________________
State ________________ Postal Code ________________
Country ________________
 

Payment Information

___Purchase Order
___Check (Make Payable to SpellingTech)
___Money Order (Make Payable to SpellingTech)
___Visa ___ MasterCard ___ American Express ___ Discover
 
Card Number ________________________________
Expiration Date ________________________________
Cardholder Name ________________________________
 

Product Selection

DescriptionQuantityPriceTotal
MedicWords - 1 User License $89 
MedicWords - 5 User License $300 
MedicWords - 10 User License $500 
MedicWords - 25 User License $1100 
MedicWords - 50 User License $1500 
MedicWords - 75 User License $1900 
MedicWords - 100 User License $2200 
    

Shipping & Handling Costs

USA DomesticFree
International$25
Subtotal 
Tax (8.25%)
TX Residents Only
 
Shipping & Handling 
Grand Total