Purchasing PyMOL Subscriptions via FAX (1-650-328-8110)

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Due to manual credit card processing costs, this form is only accepted for purchases over 100 USD. For purchases under 1,000 USD, please consider using PayPal instead to reduce administrative cost and maximize resources for PyMOL maintenance, support, and development. Our secure (old-fashioned paper) FAX number for credit-card orders is 1-650-328-8110.

Quote or Invoice No:  _____________________________________________________
 (if no quote or invoice was issued, then please specify subscription type)
    If not already shown on the quote or invoice, then please provide...
   
PI Name (for lab subscr.):  _______________________________________ 
 
Technical/Science Contact:  _______________________________________

                    Email:  _______________________________________
                                                         (required for support)
              Voice Phone:  ___________________________ 

          Mailing Address:  _______________________________________ 
               (optional)
                            _______________________________________

Billing Contact Information (for credit card, if different than above)

          Card First Name:  _________________________  

           Card Last Name:  _________________________

     Card Billing Address:  _______________________________________
                                                                
                            _______________________________________

   City, State & Zip Code:  ___________________________________ 
                                                                 
                    Email:  _______________________________________
                                                         (required for receipt)
              Voice Phone:  ___________________________ 
 
             Type of Card:  VISA / MASTERCARD / AMEX   (circle one)

        Amount Authorized:  $__________.00  ($100 USD minimum) 

                Signature:  ___________________________________________ 
   
       Credit Card Number:  ______________________________  CSC: ________ 
                                                  VISA/MC: last 3 digits on back
          Expiration Date:  ___/_______ (MM/YYYY)    AMEX: small digits on front

You may wish to contact sales@delsci.com to confirm receipt of your order. A receipt will be provided via EMAIL as soon as your order is processed. As a matter of policy, we do not retain your credit card information beyond the transaction.