Maintenance & Support Agreement Fax (Term: 12 Months)

Annual Maintenance program includes: unlimited technical support during the hours of 8 AM and 6 PM, EST, Monday through Friday.  All major upgrades will be shipped to the Software Licensing Administrator listed below.  The Technical Support Department can be reached at support.powerlan-usa.com.
 
Renewal Payment is due each year before expiration date of Maintenance.  If at any time during the term of this agreement there is a change in contacts, Licensee Administrator must notify Powerlan-USA, Inc. of such change.
 
Please complete the information above and email it to or fax it to 603.882.8884.  All upgrades will be shipped to the "Licensee Administrator" named above.
 

ALL     FIELDS REQUIRED: Please fill in the form in it's entirety so we may better serve you!
 

Printer Friendly Maintenance Purchase by FAX or Mail: Type out form completely then print and fax!

Start Date:  Expiration Date: 
 
License Information:
Company:
Check here if Bill to is same as Ship To Address
 Bill to Address:
 		Ship to Address: 
 
Licensee Administrator:
 		Phone:
Technical Contact:
 		Fax:
Email:
 		 
 
Product Information: (If need be, attach additional serial numbers to a separate sheet and fax it along with this form)
Product Name: Version: 
Serial Numbers: