Academic Institution - Request to Subscribe to agcensus

INSTITUTION

Full name:.........................................................

The annual subscription covers the period up to and including 31 July 2009.

Monthly pro-rata adjustments apply to institutions that subscribe part-way through a subscription year.

I enclose a purchase order for the amount below to cover the subscription period.


.................................... + VAT


Purchase Order No.........................................................

Full internal postal address for delivery of invoice:

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.............................................................................................................

SITE REPRESENTATIVE DETAILS

Name:.................................................. Job Title.....................................

Department:....................................................................

Address:.........................................................................

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............................................................ Post Code...............................

Tel no.:................................................. Fax no.:..................................

Email:...................................................

AUTHORISATION

Name:................................................... Job Title.................................

Tel no.:................................................. Fax no.:..................................

Email:...................................................

Signature:............................................... Date:........................................

Please return this form by FAX to EDINA: 0131 650 3308; and send the original form and the purchase order form by post to: EDINA, Causewayside House, 160 Causewayside, Edinburgh, EH9 1PR.