PROM LoanMaker (NY) Order Form

Your Name

_______________________________________________
Address

_______________________________________________
City St Zip

_______________________________________________
Telephone

_______________________________________________
Email

_______________________________________________

Print this form, 
complete it, and 

Fax it to us at 
+1 866 329 7766, or 

Call us at
+1 800 843 7766, or

Mail it to us at
PROM Software Inc
 150 Dorset St, Suite 294
South Burlington, VT 05403

We would like to order the following:

Description
# Required
Cost each
Total cost
i23n WebService (we'll contact you regarding pricing)
623N LoanMaker Handheld Calculator   $ 299.00  
623N LoanMaker Software Card Only   $ 179.00  
 
Shipping, Handling and Insurance   $ 12.00  
Total Amount of Order   

[  ]  Please bill my bank/branch at the above address for this order.

[  ]  Please charge the total amount due to my credit card as shown below:

Card Type:  [  ] MasterCard     [  ] Visa

Card Number ______ ______ ______ ______   Expires ____ / ____ 

Name on card __________________________________________

Billing address __________________________________________

______________________________________________________

Signature ______________________________________________

5 Sep 2008