TriLookup Order form (USD)

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

Trimill Industrial Systems Inc.
417-103-2609 Westview Drive
North Vancouver, BC
CANADA V7N 4N2

Order TriLookup License(s)

( ) TriLookup personal license             USD ___20.-_

+ Additional licenses to the same name:

  Additional license 2-10,     ____ x USD 10.- ________

  Additional license 11-25,    ____ x USD  8.- ________

  Additional license 26-100,   ____ x USD  6.- ________

  Additional license 101-1000, ____ x USD  4.- ________

                                   Total USD: _________

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

( ) Name        ____________________________________________

( ) Company     ____________________________________________

Address         ____________________________________________

City            ____________________________________________

State/Country   ____________________________________________

Zip/Postal code ____________________________________________

Phone/FAX       ______________________ / ___________________

E-mail address  ____________________________________________

Payment:

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