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<br />, . <br />r <br />-{ <br /> <br />,. <br /> <br />Acronis, Inc. <br />395 Oyster Point Boulevard, Suite 115 <br />South San Francisco, CA 94080 <br />Phone: 650-875-7593 <br />Fax: 650-745-2132 <br /> <br />e <br /> <br />Order Form <br /> <br />e <br /> <br />~ Acronls <br /> <br />Compute with confidence <br /> <br />CUSTOMER SHIPPING ADDRESS <br />James Janoch <br />City of La Porte <br />604 West Fairmont Parkway <br />La Porte, TX <br />ianochhllillaoortetx.oov <br />(281) 470-5031 <br /> <br />Date: <br />Rep: <br />Tel: <br /> <br />8/23/2005 <br /> <br />Reggie Fallen <br />703 885 6879 <br /> <br />CUSTOMER BILLING ADDRESS (if different from above) <br />Name <br />Company <br />Address <br />City, State Zip <br />email <br />Phone number <br /> <br />Product Description Unit Price # of Units TOTAL <br />Acronis True Imaae Server 8.0 for Windows $ 513.28 16 $ 8.212.48 <br />Acronis Maintenance & Priority SUDDort - Servers $ 111.66 16 $ 1 786.56 <br /> $ - <br /> $ - <br /> $ - <br /> <br />[. <br /> <br />.. ....T()t~1 $.....' '..W999,04' .1 <br />Price excludes applicable taxes, If any. <br />SOl 640 3220 <br /> <br />Please provide Information below and fax completed form to <br />Method of Payment: <br /> <br />Purchase Order <br /> <br />Credit Card <br /> <br />o PO# <br />o <br /> <br />Provide detail below <br /> <br />Card Type <br />(please circle): <br /> <br />Card Number: <br /> <br />Exp. Date: <br /> <br />Name on Card: <br /> <br />AMEX <br /> <br />DISCOVER <br /> <br />MASTERCARD VISA <br /> <br />lfa~~~I~~~e':{;;~~~d~tch~3.~~~re~;..;!e~sF:';.~~~e..:.'" .... <br /> <br />. , .. :. .......:: ~. ..~. <br />39'5 0 S1:e <br />......."......;!.... ... <br />Sout - <br /> <br />Signature <br /> <br />Date <br /> <br /> <br />.".!::...:" <br /> <br />Customer Purchase Authorization: <br /> <br />.':.i-..:..... <br /> <br />"".,. . <br />: ri".;" .. . ~.. . <br /> <br />Name <br /> <br />Title <br /> <br />Phone Number <br /> <br />Emall <br /> <br />Acronis Approval: <br /> <br />Sales Approval: <br />Finance Approval: <br /> <br />" <br />