| TO ORDER: Print this form, complete it and mail or fax it to:

Golden Hills Software, Inc. Attention: Order Processing 6512 Hawkeye Circle Colorado Springs, CO 80919 Fax: 719-623-0317 Sales: 719-660-6272

Date: |

About You
Name: |
Organization: |
Phone: |
Mailing Address: (No post office boxes) |
E-Mail: |
Payment Options (Choose One)
(Option 1) PO # |
(Option 2) Payment | Include payment as specified below**

Your Order
Description | Price* | Quantity | Extended Total
SurveyGold for Windows Standard Edition Product ID: 42918 |
Individual license | 199.00
Site license*** | 1999.00
Corporate license**** | Call
SurveyGold for Windows Professional Edition Product ID: 56941 |
Individual license | 299.00
Site license*** | 2999.00
Corporate license**** | Call
Shipping & Handling | 12.00
Grand Total |

###### * All prices are in US Dollars and are subject to change without notice. Should there be a difference between our published prices and the price indicated on your order, we will ask for your approval before your order is processed.

###### All faxed orders must include one of the following: ###### - purchase order and/or purchase order number ###### **All mailed orders must include one of the following: ###### - purchase order and/or purchase order number - prepaid check payable in U.S. dollars and drawn on a U.S. bank - certified bank draft drawn in the hard currency of the issuing bank - American Express money order - U.S. or International postal money order - cash in a hard currency (Golden Hills Software, Inc. takes no responsibility if you send cash, and suggests that if you do so the order be sent by registered mail.) ###### ***A site license allows multiple copies of SurveyGold to be loaded from a CD-ROM onto an unlimited number of computers at your site as described in the site license agreement. ****A corporate license allows multiple copies of SurveyGold to be loaded from a CD-ROM onto an unlimited number of computers at any corporate factility as described in the corporate license agreement.