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Note: All information provided on this form is kept in strict
confidence.  Printable
Version
1. Contact Information
Name _________________________ School or Organization Name:
___________________________
Street Address: ______________________________________________________________________
City:____________________________________ State: _____________
ZIP Code: _______________
Country: ________________________ E-mail Address: _____________________________________
Daytime Phone: __________________________________ Fax: ______________________________
2. Billing Information
Purchase Order / Check #:____________________________________________________________
Date Authorization Issued: ____________________________________________________________
Authorized Name: ________________________________ Title: ______________________________
3. Choose # of Staff Members Included With License ( Prices
are in U.S. Dollars)
______ 13 - 25 Teachers: Grants one year of access
to 13 - 25 Teachers. $350.
______ 26 - 50 Teachers: Grants one year of access
to 26 - 50 Teachers. $500.
______ 51 - 75 Teachers: Grants one year of access
to 51-75 Teachers. $650.
______ 76 - 100 Teachers: Grants one year of access
to 76-100 Teachers. $750.
4. Licensing Agreement
All materials can be used and photocopied for classroom use
only. Our products cannot be used for commerical means.
Signature: X_______________________________________________
5. Submitting Order
In order to finalize the order:
- Choose an email address that will serve as the Username
for this account: _______________
- Choose a password for this account: _________________
- Mail purchase order, check, money order, or credit card
information to:
Teachnology, Inc.
Attention: Makeworksheet.com
PO Box 1107
Truro, MA 02666
USA
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