(Rates in U.S. dollars and are subject to change)

Please select products below and mail or fax this form to:
    STAT-USA                                       Fax: (202) 482-2164
    HCHB Room 4879                                 Voice numbers:  
    U.S. Department of Commerce                        (202) 482-1986
    Washington, DC 20230                               1-800-STAT-USA
       Federal ID Number: 52-1259974                   1-800-782-8872
STAT-USA/Internet (http://www.stat-usa.gov):
 
Institution Type (please select one and fill in the corresponding pricing requirements):

Educational (4-year program)  ____ FTE Undergraduate: ____ x $.30   = _________
FTE Graduate: ____ x $.45   = _________

Community College (2-year program) ____ FTE Students: ____ x $.20   = _________

Library ____ Number of Workstations: ____ x $10.00 = _________

Standard (non-educational) ____ Number of Users: ____ $600 per 10 users = _________

TOTAL COST:  __________________
     
Maximums, Minimums, and Rounding:  The minimum charge is $500 and prices are rounded up to the nearest $50.  The maximum charge is $8,000 for an Educational or Community College, $7,000 for a Library, and $100,000 for a Standard license.

METHOD OF PAYMENT:
 (__) Credit card:     (__) American Express (__) VISA
                       (__) MasterCard       (__) Discover

    Credit card number _________________________________ Exp Date ___________

    Name ____________________________________________________________________

    Signature _______________________________________________________________
 (__) Check or money order payable to "STAT-USA" -- DO NOT FAX THESE!

MAILING ADDRESS:
 Contact name         ___________________________________________________

  E-mail address (required) ______________________________________________

  Company name         ___________________________________________________

  Street address       ___________________________________________________

                       ___________________________________________________

  City, State, ZIP     ___________________________________________________

  Country (if not USA) ___________________________________________________

  Day-time phone     (_____) _____________________________________________

  Fax number         (_____) _____________________________________________

  Numeric IP addresses (required for Shared Access Account):

    ______________________________________________________________________

    ______________________________________________________________________