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Unlimited Use Order Form Canada (GST)

Yes! I want to continue using Donarius® beyond the 30 day trial period.
Please send me an activation code for the base version plus these modules:
 [] Pledge Tracking The base version is $67.97
 [] "Gifts in Kind" and "Gifts with Advantage" and each module is $18.00
 [] Pre-authorized Deposits / Online Donations Subtract 25% from your order
 [] Customized Tax Receipts if you will have 100 active
 [] Letters, Emails & Text Messages donors per year or less
 [] Relationships and Families
 [] Photo Directory

My Serial # is: A3 - _____ - _____    (click on Serial Number on the main window)
Name:  _________________________________
Church:  _________________________________
Address:  _________________________________
  _________________________________

Here is my phone #, in case you need to contact me: _________________

Send the activation code to this email address: ___________________________

I would like to pay:
[] with a cheque or money order for the
 amount in the chart below, payable to: 
Nuverb Systems Inc.
27 Lawnview Dr.
Toronto, ON   M2N 5J9
[] Send me a CD - I will add $10.00 + GST to my cheque.

[] by VISA, MasterCard, AMEX or Discover
Charge my card for the amount circled in the chart below

Card #: _______ _______ _______ _______ Expiry Date: ___ / ______

Name on Card: ______________________ Signature: _____________________

Total cost with GST depending on how many modules you want:
Just Base Version    1 Module    2 Modules    3 Modules    4 Modules    5 Modules
  $71.37                $90.27        $109.17       $128.07       $146.97       $165.87
Total cost with 25% off:
  $53.53                $67.70         $81.88         $96.05        $110.23       $124.40

Thank You GST# 882072374
A receipt will be sent to you by email. All items are F.O.B. Toronto, Canada