Complete the Information Section Below and Sign the Form. All Requested Information Is

Complete the information section below and sign the form. All requested information is required. Upon approval, Intuit Inc will automatically charge your bank account or credit card for the amount indicated plus any sales tax, if applicable. Fax to 888-390-6542 or email to us.

Company Name
End user Details
Contact Name
Street Address
City, State Zip
Phone
Email:
QuickBooks Software / No. of Licenses / Amount
Per agreement
Pro
Premier
Premier Accountant
Enterprise
Online QuickBooks – 35% off lifetime
Point of Sale
Hosting
Checks & Deposit Slip – 35% off

Total: ______+ sales tax, if applicable

ACH Information
Bank Routing No
Bank Account No
Bank Account Type / Checking Savings
Bank Name
Credit Card Info / Visa, MasterCard, American Express, Discover
Credit Card No
Expiration Date / Security Code
Cardholder Name
Address (if different)

If payment information is other than the end user, please include all contact info & email

Notes:______

Customer's signature: ______Date: ______

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