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Total Cost:
Member Type:   Full Member Affiliate Member
 
Institution Type: Academic 2-yr Academic 4-yr
Public Library School Library State Library
Gov't. Agencies Non-profit Org. Corporate Library

NELINET debits your Core (C) account for these charges. To apply charges to a different account, indicate the account letter: _______.
Check One Payment Option Below:
1. Prepayment: Institution check enclosed
  Debit my deposit account
  I want to prepay, please send an advance
     invoice
2. Invoice: Invoice for payment at later date (NELINET
     will add an invoicing charge to purchase price)
Payment in advance provides the lowest price. You will receive invoice notification when the product has been delivered to your institution, and charged to your account. Library Supplies carry an additional invoicing charge if there is not sufficient money on account when the order is invoiced. NELINET will not issue refunds or credits beyond the individual vendor refund policy.
Signature of Designated Official Representative or Authorized Person

Signature		 Date

Mail or Fax to: NELINET, Inc., 153 Cordaville Road, Suite 200, Southborough, MA 01772 ~ Fax (508) 460-9455

April 8, 2004

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NELINET, Inc.,   153 Cordaville Road, Southborough, MA 01772   1.800.NELINET (tel)  508.460.9455 (fax)