PhotoRescue Site License Order Form : to be faxed to +32-4-3446514

Shipping address 
Name		
Company		
Address		
Address		
City		Country		
Phone		Fax		
E-mail		
VAT*		Applies to EU corporations only	

Billing Address
Name		
Company		
Address		
Address		
City		Country		
Phone		Fax		

Credit Card Information						Signature
Credit Card Type	          Visa J          MasterCard J	
Credit Card Number		
Expiration Date		
Signature		

Product
Product	Size of license	Quantity	Price		
PhotoRescue	10		129 USD		
PhotoRescue	20		199 USD		
PhotoRescue	40		359 USD		
PhotoRescue	60		479 USD		
PhotoRescue	80		595 USD		
PhotoRescue	100		795 USD		
PhotoRescue	200		1495 USD		
PhotoRescue	500		2495 USD		
PhotoRescue	Gold Disk		4995 USD		
		Subtotal		
		VAT 21%*		
		Total		
DataRescue sa/nv					--- Banking Information ---
40 Blvd Piercot					Fortis Bank    
4000 Liège, Belgium					rue Montagne du Parc 3
VAT: BE-448270553 					1000 Brussels, Belgium
Tel : +32-3446510					SWIFT GEBA-BEBB
Fax: +32-3446514					account : BE13 0012 7102 4039 (EUR) 
e-mail : sales@datarescue.com			account : BE12 0054 3431 7892 (USD)

I am paying by advance bank transfer, please register my order and wait for payment                    J	
I want to send a purchase order (governments, fortune 1000 and existing customer only)              J	

(*) VAT applies only in EU.  EU Companies should either provide their VAT number or add the Belgian VAT. Private Users should add the Belgian VAT