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ASR SANTA ANA ENQUESTA AND INVOICE CLOUD INTEGRATION 03-24-16.DOCX <br />Date: <br />Billing Information <br />April 12, 2016 <br />Page 5 of 5 <br />Please complete the billing and delivery information in the form below. If you require your purchase order number to be <br />included on invoices issued by System Innovators, please include the purchase order number in the form. <br />Bill To <br />Deliver To <br />Name: <br />Name: <br />Title: <br />Title: <br />Address: <br />Address: <br />City, State Zip: <br />City, State Zip: <br />Telephone: <br />Telephone: <br />E-mail: <br />E-mail: <br />PO #: <br />Note: This offer will expire on May 31, 2016 unless extended in writing by System Innovators. Upon <br />completing this investment schedule, please scan and e-mail all pages of the investment schedule to <br />System Innovators at mmoctezuma@systeminnovators.com. <br />System Innovators cannot schedule nor proceed with any work on this additional service until the client <br />has 1) provided all of the information requested in this investment schedule, 2) signed the investment <br />schedule, and 3) returned the investment schedule in its entirety to System Innovators. <br />(for internal use) <br />Project Number: ACCT#/TEAM: Professional Services Consultant: <br />System Innovators —a division of N. Harris Computers <br />800.963.5000 • Fax: 904.645-8892 <br />10550 Deerwood Park Blvd., Suite 700 <br />Jacksonville, FL 32256 <br />25F-21 <br />