OrderForm.html

ApotheSoft, LLC

2541 Perry Avenue, Bremerton, Wa. 98310

Work (360) 271-2527 Fax (360) 479-4831

Internet Page: http://ApotheSoft.com

E-Mail Address: support@apothesoft.com

Order Form Date: ___________

1) ApotheSoft-Rx Pharmacy Software Initial License $ 1825.00 _________ [ ]

Complete with 1 year FREE Software Support & Price Updates

2) ApotheSoft-Rx License Annual License Renewal $ 900.00 _________ [ ]

Complete with 1 year FREE Software Support & Price Updates

3) Lexi-Comp Drug Interaction and Drug Info $ 450.00 _________ [ ]

Lexi-Comp Requires an annual license renewal

4) Secure Off-Site Backup Module $ 150.00 _________ [ ]

Requires Annual license renewal

5) ApotheSoft-Rx Upgrade from old PPS32 program $ 1200.00 _________ [ ]

6) Other ____________________________________ $ _________ [ ]

(Fill in amount discription after talking to support.) .

Postage and Handling $ 5.00

TOTAL = ______________

By placing this order you are acknowledging that you have read and agreed to the terms and conditions as describe in the ApotheSoft Licensing agreement. A copy of this License agree can be found on the ApotheSoft website located at www.apothesoft.com as well as during program installation.

Your Name: ______________________________ Phone#: _______________

Pharmacy: ______________________________ NCPDP#: ______________

   Address: _________________________________________________

  City, State: ______________________________________________

   NPI#: ____________________ Fax#: ____________________

Email Address: _________________________________________________