PROM 671B Mortgage Compliance Tool Order Form

Your Name

_______________________________________________
Address

_______________________________________________
City St Zip

_______________________________________________
Telephone

_______________________________________________
Email

_______________________________________________

Print this form
complete it, and 

Fax it to us at 
+1 802 862 8357, or 

Call us at
+1 855 855 8080, or

Mail it to us at
PROM Software Inc
150 Dorset St, Suite 294
South Burlington, VT 05403-6275


Please ship the following items:

Description
# Required
Cost each
Total cost
671B Mortgage Compliance Tool Calculator   $329.00  
CE-123P Printer (Subject to availability)   $169.00  
671B Mortgage Compliance Tool Software
Instant Upgrade  (for existing calculators)
  $169.00  
Shipping and Insurance (2-day service)   $12.00  
Total Amount Due   

[  ]  I have enclosed a check with this order form for the total amount due.

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

Card Type:  [  ] American Express    [  ] MasterCard     [  ] Visa

Card Number ______ ______ ______ ______   Expires ____ / ____ 

Name on card __________________________________________

Billing address __________________________________________

______________________________________________________

Signature ______________________________________________

5.26.2011