SHIP TO:
Organization: ________________________________________________________________________
Name:_______________________________________________________________________________
Address: _____________________________________________________________________________
______________________________________________________________________________________
City: ________________________________________ State/Province:__________________________
Country: _____________________________________ Postal Code: ___________________________
Telephone: _________________________________ Cell phone: ____________________________
Email: _____________________________________________
Cost US Dollars (includes all tax, shipping and handling:
Basic Program: $3500
Pumping Plan Version: $4000 (tailored to your floating dry dock)
PAYMENT INFORMATION:
Check: Make checks payable to DM Consulting.
Credit Card: VISA MasterCard
Amex (circle one)
Card Number: ______________________________________________________________________
Expiration Date: ____________________________________________________________________
Cardholder Name: __________________________________________________________________
Cardholder Address: ________________________________________________________________
___________________________________________________________________________________
City: ________________________________ State/Province: _______________________________
Country: ________________________________ Postal Code: ____________________________
Cardholder Telephone: _________________________ Cardholder Fax: _____________________
