Agreement Form

Please submit Agreement Form before placing order.
In order to qualify for Discount Prices, buyer must agree to submit a Survey evaluating the Paint Careers With Colors product.

Paint Careers With Colors Agreement Form

Please note that all fields followed by an asterisk must be filled in.

First Name*

Last Name*

E-Mail Address*

Web Site URL*

Street Address

City*

State/Prov*

Zip/Postal Code*

Country*

Home Phone*

Business Phone*

Fax

Job Title:*

Name of School or Organization:*

Contact Time: When can we contact you to explain the program?
(By phone, US Customers only; By e-mail, Overseas Customers)*

Product Title: e.g. 50 Paint Careers With Colors CD-ROMS*

Name of School or Organization where Paint Careers With Colors will used used:*

Potential Number of Students/ Clients Using the Paint Careers With Colors:*

I agree to complete Evaluation Survey within 90 days of receiving the Paint Careers With Colors System.*

	Yes
	No

Please enter the word that you see below.

Get motivated and inspired! Text/ call us at (602) 753-9112 (12pm to 5pm GMT-07:00) or moreinfo@hollandcodes.com. 4133 E. Siesta Ln. Phoenix, AZ 85050, Copyright © 2004-2017 Dr. Mary Askew. All Rights Reserved.