Data Banc Systems Order Form

• ORDER FORM

Order Form

Please Use This Form to Request a Count of the Number of Records and the Cost of the Lists You Desire.

We will return to you an invoice for your approval of the project's cost. For your protection, we will NOT process your order until that invoice is signed and faxed back to us. (FAX Number 817-284-1890)

Contact Information:
*required fields

* Date (mm/dd/yy):

* Name:

Company:

* Address 1:

Address 2:

* City:

* State:

* Zip Code:

* E-Mail Address:

Phone Number (xxx) xxx-xxxx:

Fax Number (xxx) xxx-xxxx:

Toll-Free Number (if Available)

Shipping Information (if different than the above address):

Ship To:

Address 1:

Address 2:

City:

State:

Zip Code:

Please List Below the States, Companies, SFC or Zip Codes

* States, Companies, SCF or Zip Codes Requested (one entry per line)

Do You Want Phone Numbers?
Phone Numbers Where Available (FREE for Texas, $0.025 per phone number for other states)

Phone Number Records Only (FREE for Texas, $0.025 per phone number for other states)

* Choose the Format of the List
Peel and Stick Labels
Computer Paper (label format 3 or 4 across)
3.5" Disk IBM Format ASCII Comma Delimited File ($25.00 set-up fee)
CD-ROM IBM Format ASCII Comma Delimited File ($25.00 set-up fee)

* List Sorted by Zip Code or Alphabetically by Last Name of Agent?
Zip Code
Alphabetically