PC SHARE REGISTER PLUS - REGISTRATION FORM

I/We hereby apply to register one copy of PC Share Register Plus to be licensed for a period of 1 year in accordance with BHIS Limited licence agreement as follows:

Name of Company/Business

Amount Payable

Nature of Business

Postal address

Telephone number

Fax number

e-mail address

Contact name

Number of licensed companies

[10 = £115] [25 = £255] [75 = £435]

[150 = £640] [250 = £760] [400 = £925] [550 = £1090] [700 = £1255]

[850 = £1420] [1000 = £1585]

Base Cost

£

I also require the eFiling Module

 Yes / No  [+ 25% x Base Cost]

£

I also require the Data Exchange Module

 Yes / No  [+ 15% x Base Cost]

£

I also require the Forms Module (Forms Online) - £49 per concurrent user

 No. Users:     [+ £49 per user]

£

I also require the Scanned Documents Module

 Yes / No  [+ 50% x Base Cost]

£

I also require the Security Module

 Yes / No  [+ 50% x Base Cost]

£

I also require the Companies House Data Check Plus Module

 Yes / No  [+ 10% x Base Cost]

£

Total Net of VAT (annually in advance)

£

VAT @ 17.5%

£

Total Including VAT

£

Where did you hear about the program?

Signed

Date

Full name

Position

Payment

A cheque is enclosed for the above amount, made payable to BHIS Limited

or

Please charge to the following credit card:

 Please tick required option

  [  ]

  [  ]

Your name (as shown on the card)

Card type (eg. Visa, Mastercard etc.)

We do not accept American Express or Diners Club

Card number

Card issue number (if applicable)

Card start date (if applicable)

Card expiry date

Card security code (last 3 digits on reverse)

I hereby authorise BHIS Limited to charge the total amount due to the above credit card account

Cardholder's signature

Please print out this form and fax completed application form to

BHIS Limited on 020 7117 1047

or post to BHIS Limited, Manor House, 58 Manor Wood Road, Purley Surrey, CR8 4LF.