DATASENSE, LLC - Order Form - XSight 2
QSR International Partner (USA)                                                                 

Fax form to (661) 215.9379 or email kconger@datasense.org
Prices subject to change without notice 

Registrant: Name: (last)_________________________(first)_____________________middle initial)_____
Institution:________________________________________________________________________________
Shipping: P.O. Box or street address (P.O. Box not accepted by Fed Ex):
_____________________________________________________________________________Apt./Suite: ____
City: ___________________________________________________________ State: ______ Zip: ___________
Phone: (home) (____) _________________ (work) (____) _________________Fax: (____) _________________
Phone for Shipping Label: (____) _________________
Email address for confirmation:__________________________________________________________________

Method and Authorization of Payment (check one):
University Purchase Order #________ (attach PO and fax to 661.215.9379)
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: _____________
Email address for receipt if different from registrant:_______________________________________________
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. Fax to 661.215.9379 or mail to mailing address shown at bottom of form.

ACADEMIC pricing applies if you’re a student, teacher or an academic who is learning, instructing or undertaking research at an
educational institution or you work for a non-profit organization.  GOVERNMENT pricing applies if you belong to a federal, state,
or local government or agency that is undertaking research.  COMMERCIAL pricing applies to everything else.
BULK PURCHASE DISCOUNTS apply to software with the same delivery method. For example, purchase 4 download versions
and receive a 10% discount, or purchase 4 boxed copies and receive a 10% discount. No discount would apply however, if you
purchased 2 download versions plus 2 boxed copies.

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