DATASENSE, LLC - Order Form - Qualrus
                      
Fax form to (661) 215.9379 or email kconger@datasense.org
Prices subject to change without notice 

Purchaser: Name: (last) _______________________(first) __________________(middle initial)_____
Institution: ________________________________________________________________________
Shipping street address (box number not accepted by carriers):
____________________________________________________________________Apt./Suite: ____
City: _____________________________________ State: ______ Zip: ____________
Phone: (home) (____) ________________ (work) (____) _______________
Phone for Shipping Label: (____) __________ Email address for confirmation:___________________________

Method and Authorization of Payment (check one):
University Purchase Order #________ (attach PO)
Credit card: ___ VISA© ___MasterCard© ___American Express
Card number: ___________________________________ Expires (MM/YY): ______________
Exact name as it appears on card___________________________________________________
Billing address for card:____________________________________________ Apt./Suite: ____
City: ____________________________________________ State: ______ Zip: _____________

Authorizing signature: _____________________________________ Date: _________
(I HEREBY AGREE TO COMPLY WITH ALL OF THE TERMS OF THE CARDHOLDER AGREEMENT)
To prevent unauthorized use of your credit card DATASENSE, LLC requires that all charge card users sign on the
Authorized Signature line of this form. For immediate processing, please fax a signed copy to 661-215-9379 or mail
the original form to the address shown below. Thank you.

• Academic pricing: in order to qualify, you must be a staff member of an accredited academic institution, non-profit organization,
or government branch. We require that you specify your position, your department name, and the name of the institution before
purchasing.• Student pricing: in order to qualify, you must be a full-time student at an accredited academic institution. We require a
fax of a student picture ID, or other similar proof of status. There is no student pricing for site-licenses. • Standard pricing applies to
all other customers. This includes private parties, consultants, and commercial ventures. Individual licenses require that you designate by
name specific individuals authorized to use the program, and that the number of such individuals is the same as the number of licenses which
you purchased. So long as the above condition is met, there is no limitation on the number of computers where the program can be installed.

Mailing Address:
DATASENSE, LLC
25101 Bear Valley Road, Suite 297
Tehachapi, CA 93561-8311

Ph: (661) 821-1909           Fax: (661) 215-9379  
Email: kconger@datasense.org