TriLookup Order form (CAD)

Please print, fill out and send this order form together with your payment to the following address:

Trimill Industrial Systems
530 West 19th Street
North Vancouver, BC
CANADA V7M 1X9

Order TriLookup License(s)

( ) TriLookup personal license             CAD ___30.-_

+ Additional licenses to the same name:

  Additional license 2-10,     ____ x CAD 15.- ________

  Additional license 11-25,    ____ x CAD 12.- ________

  Additional license 26-100,   ____ x CAD  9.- ________

  Additional license 101-1000, ____ x CAD  6.- ________

                                   Total CAD: _________

Registered User Name (your name OR company name - please check off):

( ) Name        ____________________________________________

( ) Company     ____________________________________________

Address         ____________________________________________

City            ____________________________________________

Province/Country____________________________________________

Zip/Postal code ____________________________________________

Phone/FAX       ______________________ / ___________________

E-mail address  ____________________________________________

Payment:

( )Check ( )Money Order ( )Cash ( )Purchase Order #:________