Purchase Request Form

In order to purchase GoldSim or Renewal, please fill out this form. After we receive the form, we will contact you to complete the transaction.

Step 1/4: Product Selection:

What do you want to do?

License Quantity:

Your total is:

Multiple license purchases may be subject to volume discounts. Upon receipt of your purchase request, GoldSim will contact you with a final price quote.

	Components:	Quantity:
	GoldSim Pro or GoldSim Research
	Distributed Processing Module Plus
	Floating Network License
	Reliability Module
	Contaminant Transport Module
	Radionuclide Transport Module

Number of subscriptions to renew:

Instructions or comments regarding this subscription renewal:

Step 2/4: Buyer Contact Information

* First Name			* Last Name
* Organization			* Address
* City			* State or Province
* Postal Code			* Country
* Email			* Email Confirmation
* Telephone			Fax

Step 3/4: Licensee Contact Information

I am the primary technical contact for this license purchase.
I am acting as a third party (purchasing agent or distributor) for this purchase. The actual user's contact information is provided below:

First Name			Last Name
Organization			Address
City			State or Province
Country			Postal Code
Email			Telephone
Fax

Step 4/4: Payment Details:

I will pay by credit card	If paying by credit card, call 1-425-295-6985 (-8 hours GMT) or fax 1-425-642-8073 to complete transaction
Invoice Me OR Invoice Accounts Payable	AP information below must be filled out.

Purchaser's Tax ID Number			Other Purchase Notes
Purchase Order Number

NOTE: GoldSim's standard method of invoicing and providing receipts is via email. If you wish to receive a paper invoice or receipt instead, check here:

Accounts Payable Information

First Name			Last Name
Organization			Address
City			State or Province
Country			Postal Code
Email			Telephone
Fax

Note that you will not be charged when you submit this form. This order is not valid until accepted by GoldSim Technology Group. We will contact you to complete the transaction.

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