Order Account and/or Services

Software/Services Selection:
 
  Item Setup Charge Monthly Rate
BizWizard Order Manager: $0.00 $0.00
BizWizard ShopKart    
$0.00 $0.00
       
 
Promo Code: Bundle/Promo Discount:
($0.00) ($0.00)
    =========== ==========
Month to Month? Totals: $0.00 $0.00
 
Customer Information:
Company Name: * (e.g. Awards Store USA)
Address One: * (e.g. 1234 N. Main Street)
Address Two: * (e.g. Reno, NV 89506)
Address Three:
 
Phone: * (e.g. 775-996-1343)
Toll-Free Phone: (e.g. 877-370-6870)
Fascimile Phone: (e.g. 775-986-5127)
 
Web Site Addresses
Current Web Site: http://
ShopKart Web Site: http://
 
Responsible Party
Name: * (e.g. John Doe)
Address One: * (e.g. 1234 N. Main Street)
Address Two: * (e.g. Reno, NV 89506)
Address Three:
Phone: * (e.g. 775-996-1343)
E-Mail: *
 
Activation/Initialization
Activation Date: * (YYYY-MM-DD)
Initial Product Markup:* (percentage increase from the suppliers cost)
 
Payment Information:
Card Type:*
Card Number:* (xxxx-xxxx-xxxx-xxxx)
Expiration Date:*
Name on Card:* (e.g. John Doe)
Billing Address:* (e.g. 1234 N. Main Street)
  (e.g. Reno, NV 89506)