Custom Direct Sales Order Form

Direct Sales Order Form (CUSTOM)
Model(s)
- 9420
- 9430
Date*
MM slash DD slash YYYY
Sales Representative*
Location*
Other Location (fill in)
Eyecon with Penicillin, Sulfa and Hazard Platters
9420 Special Price
9420 Quantity
9430 Special Price
9430 Quantity
Net Total
Shipping
Total
Notification and Access of Maintenance Update Files
Periodic drug database maintenance is required to assure your Eyecon is current with the latest drug information.
I Acknowledge the Eyecon Software License Agreement Includes:
- The MEDI-SPAN drug database is licensed, third party owned and may not be duplicated, sold, or removed from the Eyecon.
- Upon purchase, the Eyecon will be registered on the Eyecon website - EyeconVPC.com
- The Eyecon must be kept up-to-date with the latest MEDI-SPAN drug database.
- All Eyecon units include an initial 12 months MEDI-SPAN subscription, thereafter, charged at $279.00 annual fee to maintain access to the updates.
- I have the ability to receive update notifications via email.
- I am authorized by my company to accept the maintenance terms above.
Initials*
Confidential Customer Information
By completing the following information and signing this document, the undersigned agrees to the license terms as set forth in the Eyecon Software Product License Agreement.
Sold to:
Business Name
Contact
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Fax
Ship to:
Same as Sold To:
- Yes
Business Name
Contact
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email (required to register new unit)*
Payment method: Payment is required when shipment is ready*
- Prepay by Check
- ACH Prepayment
- Credit Card [ Call: (507) 238-4461 ]
- Mail Check [ To: Avery Weigh-Tronix LLC | 75 Remittance Drive, Suite #1982 | Chicago, IL 60675-1982 | c/o: acct# 77YECC ]
- Financing [ ENTER BELOW ]
Financing Option
Signature*
Date*
MM slash DD slash YYYY
An order acknowledgement will be emailed or faxed when the order is processed. The projected date of shipment will be included with the order acknowledgement. Prepayment by check or credit card will be requested when shipment is ready.

Direct Sales Order Form (CUSTOM)

Eyecon with Penicillin, Sulfa and Hazard Platters

Notification and Access of Maintenance Update Files

I Acknowledge the Eyecon Software License Agreement Includes:

Confidential Customer Information

Sold to:

Ship to:

Eyecon®