Please complete the following application, and click the Continue button to view a printable version of this form. In order to process your application, we will need to receive a signed and dated copy of the completed form. The signed and dated copy should be faxed to +1-217-398-0747, Attn: Finance, or you can send it to the following address:
Accounts Receivable Wolfram Research, Inc. 100 Trade Center Drive Champaign, IL 61820-7237
If you have any questions, please send email to Wolfram Education Group at education@wolfram.com.
Date submitted: 5 July 2008
Required fields are indicated with an asterisk (*).
*Organization
Branch name (if applicable)
*Billing address
*City
*State
*ZIP code
*Country
Shipping address (for course materials) (if different from above)
City
State
ZIP code
Country
*Type of business (e.g., corporation, subsidiary corporation, joint venture, sole proprietor, partnership)
*Annual sales
*Years in business
*Amount of training credit requested
*Dun & Bradstreet number
If subsidiary, name of parent company
Address
*Name
*Title
*Telephone
Name
Title
Telephone
*Email address
*Fax
*Bank name
*Address
*Account number
