	Digital Signature Request Form
Company Name:
Address:
City: State: Zip:
Telephone: Fax:
Email:

Payment Information

No Checks Accepted for Digital Signatures

Digital signature(s) at $50.00 each

$ ___________

Taxes (if applicable):

9% - E. Baton Rouge, LA

5% - Elsewhere in LA

7.5% - Mecklenburg County, NC

7% - Elsewhere in NC

x _____ % =

$ ___________

Shipping & Handling:

$ 10.00

Total =

$ ___________

Credit Card: American Express [ ] Mastercard [ ] Visa [ ] Discover [ ]

3-digit CV2 Code:

Expiration Date: /

Signature: _________________________________________________________________

Specify Color of your Signature: Black [ ] Blue [ ]

Instructions:

Use a black medium point pen.
Please list all active users of your software on Page 2.
If this is not filled in, it will take longer to receive your signature.
Sign between the shaded areas provided on Page 3.
Mail this original form to:

7423 Picardy Ave., Suite F

Baton Rouge, LA 70808

You must mail the original – faxes will not be accepted!

Please provide list of all active appraisers currently using your software.

**Note: If this information is not filled in, it will take longer to process your order.

Please print name(s) here for requested signature(s):

_____________________________________________________________________

- Make sure none of your signature loops or flourishes extend above or below assigned
areas (see example at bottom of page).

- Please provide a signature in each block available.

Sign below

Sign above

Digital Signature Request Form