Teachnology Platinum Membership Offline Site License Sign-up Form

Note: All information provided on this form is kept in strict confidence.

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:

1. Choose an email address that will serve as the Username for this account: _______________
   
   
2. Choose a password for this account: _________________
   
   
3. Mail purchase order, check, money order, or credit card information to:

Teachnology, Inc.
Attention: Makeworksheet.com
PO Box 1107
Truro, MA 02666
USA