Escrow Services - Order form

Please ensure that all parts of this form are filled out as accurately as possible, to avoid delays with processing your application. Should you require help with completing the form, please call our helpline on 0800 043 3360.

Please note that an agreement cannot commence without full payment details, and a valid purchase order number.

1.Contact details

Licensee contact details
Contact name
Position
Registered office address
Correspondence address
(if different from above)
Phone number
Fax number
Email address
Software owner contact details
Contact name
Position
Company name
Registered office address
Correspondence address
(if different from above)
Phone number
Fax number
Email address

2.Invoicing details

Licensee invoice details (if applicable)
Approved purchase order number
Name of person to be invoiced
Position
Company
Invoicing Address
(if different to address in section 1)
Phone number
Fax number
Email address
Software owner invoice details (if applicable)
Approved purchase order number
Name of person to be invoiced
Position
Company
Invoicing Address
(if different to address in section 1)
Phone number
Fax number
Email address
  1. Party responsible for payment of individual fees

(please tick for each service)

Owner / Licensee
Initial set-up fee
Annual subscription – single licensee
Multi licensees – additional subscription
Additional deposits
Customised agreement
Escrow Assist
Full verification
Release fee
Site licence

4.Materials to be deposited

Agreement type
(i.e. single/multiple licensees)
Software package to be deposited
  1. Fees (for a full description of each service please refer to our price list available on our website).

Service / Fee / Quantity / Cost
Initial set up / FoC
Annual subscription - single licensee / £650
Multi licensees –
additional subscription / £350
Additional deposits / £125
Customised agreement / £125 p/hour
Escrow Assist – annual subscription / £800
Full verification / £5,000
Release fee / £100
Site licence fee / Price upon application
Sub Total / £
VAT @ 17.5% / £
Total / £
If you wish to enclose payment upon application, please make cheques payable to Software Escrow Services.
  1. Declaration

By completing and submitting a signed order form to Software Escrow Services, you agree to be bound by Software Escrow Services’ standard Agreement (a copy of which is available upon request).

______/ ______
Signed / Print Name
______/ ______
Position / Date

Please send all completed applications to:

By post: / Quantum House
6 Shottery Brook Office Park
Timothy’s Bridge Road
Stratford upon Avon CV37 9NR
By email: /
By fax: / 0800 043 3361