Purchase Order Number (If needed):

FAX ORDER FORM

Instructions:

1. Print out and fill in this fax order form completely.
2. Fax the form to Analytic Systems at +1-604-543-7354.
3. A representative of Analytic Systems will contact you as soon as possible, via the communications method you indicate below, to confirm your order and process your purchase information. We will contact you either on the same day, or within one working day.

PURCHASING INFORMATION

I wish to pay by:

NOTE: All purchase information will be held in the strictest confidence!
Cardholder's Name: ____________________________________
Credit Card (Circle One):
Visa MasterCard American Express
Expiration Date: _____________________________________
Card Number:
_____________________________________________________

Cardholder Signature: ________________________________

CONTACT INFORMATION
Date: ________________________________________________
First Name: ___________________________________________
Last Name: ___________________________________________
Company: ____________________________________________
E-mail Address: _______________________________________
phone_no: ___________________________________________
Facsimile: ____________________________________________
Address: _____________________________________________
_____________________________________________________
City: _________________________________________________
State/Province: ________________________________________
Country: _____________________________________________
Zip/Postal Code: ______________________________________

COMMUNICATION PREFERENCE (Circle One):
phone_no E-mail Fax Regular Mail

BEST TIME TO BE REACHED
Between __________ (AM | PM) and __________ (AM | PM)

OTHER SERVICES
Add Me to "AnalyticNews", Our Automatic E-mail Alert Service:
(for announcements of new products, special offers and other important information)

Yes _______ No _______