I/We hereby apply to register one copy of Forms Online to be
licensed for a period of 1 year in accordance with BHIS Limited licence agreement as
follows: |
| Name
of Company/Business |
|
| Nature
of Business |
|
| Postal
address |
|
| Telephone
number |
|
| Fax
number |
|
| e-mail
address |
|
| Contact
name |
|
|
Number of users (£49 + VAT per concurrent user) |
|
| Details
of hardware |
|
| Operating
system |
|
| Where
did you hear about the program? |
|
| Signed |
|
| Date |
|
| Full
name |
|
| Position |
|
| Payment |
|
| Total
amount due (annually in advance) including VAT |
£ |
A
cheque is enclosed for the above amount, made payable to BHIS Limited
or
Please charge to the following credit card: |
Please
tick required option
[ ]
[ ]
|
| Card
name (your name as shown on the card) |
|
| Card
type (eg. Visa, Mastercard etc.)* *We are unable to accept American Express or Diners Club cards |
|
| Card
number |
|
| Card
issue number (if applicable) |
|
| Card
start date (if applicable) |
|
| Card
expiry date |
|
Card
security code
(last 3 digits on reverse of card) |
|
I hereby authorise
BHIS Limited to charge the total amount due to the above credit card account |
| Cardholder's
signature |
|
| |
Please print out this form and fax
completed application form to
BHIS Limited on 020 7117 1047
or post to BHIS Limited, Manor House, 58 Manor Wood Road, Purley
Surrey, CR8 4LF.
|
