Your Name

Your Position

Practice Name

Practice Address

Post Code

Email

Phone Number

Number of Nominated Users to be licensed to use QUAD Business Builder in the above Practice
(Numeric value please)

Please supply a 12-month licence granting the specified number of Nominated Users unlimited use of the following QUAD Business Builder software in the United Kingdom:-

I confirm that my practice is a member of the following qualifying organisation(s) :-

I understand that the Licence Fee will be based on the price matrix in the 'Order' page adjusted for any discount arising from membership of a qualifying organization (see above) and I undertake to procure the settlement of your invoice for this amount within 14 days of receipt of the software.