MedicWords Order Form
You can print this order form out and mail it to us.

Broader Technologies, Inc.
P.O. Box 751
Round Rock TX 78680
 

Date:______________

How did you hear about MedicWords?____________
 

Billing Information:
Name:____________________________________
Company:_________________________________
Phone:(____)_________________EXT._________
Email:____________________________________
Address:__________________________________
City:_____________________________________
State:_________________ Zip Code:___________
 

Shipping Information:
(Leave blank if same as billing.)
Name:____________________________________
Company:_________________________________
Address:__________________________________
City:_____________________________________
State:_________________ Zip Code:___________
 

Method of Payment:
(Make Checks and Money Orders Payable to Broader Technologies, Inc.)
___Check
___Money Order
___Visa
___MasterCard
___American Express
___Discover
Credit Card Number:___________________________
Expiration Date:_______________________________
Name on Card:_______________________________
 

License Type:
Quantity Description Unit Price Total
  MedicWords 1 User License $40.00  
  MedicWords 5 User License $125.00  
  MedicWords 10 User License $200.00  
  MedicWords 25 User License $400.00  
  MedicWords 50 User License $700.00  
  MedicWords 75 User License $900.00  
  MedicWords 100 User License $1000.00  
SubTotal  

8.25% Tax
(Only Texas Residents Are Required To Pay Tax)

  
Shipping
(Deliveries within the U.S. - Priority Mail = $4.00)
(Deliveries outside the U.S. - Global Priority = $16.00)		  
Grand Total