I N T E S E L, I N C .

PROJECT FORM
 

CLIENT CONTACT INFORMATION:

Sales Persons Name:

Todays Date (mm-dd-yyyy)

Businessl Name:

Contact Full Name:

Contact Email Address:

Contact Cell Phone:

Business General Phone:

Business Street Address:

City + State:

Zip Code:

PROJECT DETAILS:

Type of Program
Select Standard SmartCard Aluminum SmartCard Standard SmartCard Wireless Aluminum SmartCard Wireless

Card Data Size
Select 128MB 256MB 500MB 1 GIG 8 GIG + Data Load Surcharge 8 GIG + Data Load Surcharge 32 GIG + Data Load Surcharge 64 GIG + Data Load Surcharge

Quantity
Select 100 250 500 1000 5000 10,000 Over 10K

Data on Card
Select Client to Provide Custom Development/OPTION> Link Only To Website Link To Custom Websit

Main Link URL:

Add QR Code:
Select Yes, Add QR code NO QR code

Shipping Address if different:

Special Notes:

Total Cost ( includes $5,000 setup fee):

CC PAYMENT DETAILS:

CC Type:
Select MC - Credit card VISA - Credit card Company Check

Credit Card #:

Exp Date: (mm-yy)

Security Code:

Actual Name Shown On Your Credit Card

Billing Address (if different from above):

I authorize Intesel, Inc. to charge the payment owed.

or