Medical Speller Order Form
You can print this order form out and mail it or fax it to us.

Fax Number: (413) 832-8487

Broader Technologies, Inc.
P.O. Box 751
Round Rock TX 78680
 

Date:______________

How did you hear about the Medical Speller?____________
 

Billing Information:
Name:____________________________________
Company:_________________________________
Phone:(____)_________________EXT._________
Email:____________________________________
Address:__________________________________
City:_____________________________________
State:_________________ Zip Code:___________
 

Shipping Information:
(Leave blank if same as billing.)
Name:____________________________________
Company:_________________________________
Address:__________________________________
City:_____________________________________
State:_________________ Zip Code:___________
 

Method of Payment:
(Make Checks and Money Orders Payable to Broader Technologies, Inc.)
___Check
___Money Order
___Visa
___MasterCard
___American Express
___Discover
Credit Card Number:___________________________
Expiration Date:_______________________________
Name on Card:_______________________________
 

License Type:
Quantity Description Unit Price Total
  Medical Speller 1 User License $29.99  
  Medical Speller 5 User License $99.99  
  Medical Speller 10 User License $169.99  
  Medical Speller 25 User License $349.99  
  Medical Speller 50 User License $599.99  
  Medical Speller 75 User License $824.99  
  Medical Speller 100 User License $899.99  
SubTotal  

8.25% Tax
(Only Texas Residents Are Required To Pay Tax)

  
Shipping
(Free)		 0.00
Grand Total