Canary Compliance: Order Form

Canary Compliance: Order Form

Canary Compliance: Order Form
Company Name
Distributor Name (Optional)
Billing & Shipping Information
Billing Contact Person

First NameLast Name
Billing Contact Email
example@example.com
Billing Contact Phone Number

Area CodePhone Number
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Shipping Recipient:

First NameLast Name
Shipping Recipient Company Name (if applicable):
Shipping Recipient Phone:

Area CodePhone Number
Shipping Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DirectDistributor
Services & Fees
“Can’t decide? Download our brochure to see which is the best fit for you”

Please fill out the below table :

Rows	No. Of Canaries / Cost
Inventory Only: ($25/site)
Canary Basic: ($30/site)
Canary Pro: ($65/site)
Canary Hardware Cost

Hardware Total Cost:
Monthly Software Total Cost:

Installation Cost (If applicable):

Rows	No. Of Sites / Cost
Install Cost Per Site:
Site Count for Installation:

Installation Total Cost:
Coupon Code:

Terms & Conditions
AnnuallyBiannuallyQuarterlyMonthly
Effective Date:

MonthDayYear
Date
Term:
Renewal:
Notice to terminate:
Additional Terms:
The pricing and terms offered herein shall not be binding upon either party until executed by both Customer and Canary Compliance.

This Canary Compliance Order Form (this "Order Form") is entered into as of the Effective Date by and between Canary Compliance, LLC ("Canary Compliance") and the customer identified below ("Customer"). Any capitalized terms used but not defined in this Order Form will have the meanings ascribed to such terms in the End User Terms provided (the "End User Terms").
Canary Compliance:
Title:
Name

First NameLast Name
Signature
Customer:
Title:
Name

First NameLast Name
Signature

User(s) Information
User 1:
Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Daily2X DailyHourly
First Export Time:

:HourMinutesAM/PM Option
Second Export Time

:HourMinutesAM/PM Option
User 2:
Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Daily2X DailyHourly
First Export Time:

:HourMinutesAM/PM Option
Second Export Time

:HourMinutesAM/PM Option
User 3:
Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Daily2X DailyHourly
First Export Time:

:HourMinutesAM/PM Option
Second Export Time

:HourMinutesAM/PM Option
Site(s)
Upload a site list: Include each site(s) name, address, and the ATG Type

Canary Supports:
- Veeder-Root TLS 300
- Veeder-Root TLS 350
- Veeder-Root TLS 450 Plus
- Franklin EVO Series
- OPW Integra
Browse Files

Cancelof

Should be Empty: