Premium Support Agreement, Onsite Service Visit, and Maintenance Kits

First Name*

Last Name*

Company*

Phone*

Cell (Mobile)

Email*

Physical Address (On-site visit location)

Street Line 1*

Street Line 2

City*

State/Province*

Postal Code*

Country*

Street Line 1*

Street Line 2

City*

State/Province*

Postal Code*

Country*

Payment Method*

Purchase Order #

If paying by credit card please fax credit card information or provide phone number. Do not enter a credit card number on this form.

Telephone # for Credit Card Info.

Juniper Systems' FAX number: 435-774-8988

Primary Contact for On-Site Visit

Name*

Phone*

Email*

P/N		Price		Systems	Cost
23467	System Maintenance (Includes Premium Support)	1200			0
234678	Additional System Maintenance (Includes Premium Support)	800			0
P/N		Price	Systems	Yrs	Cost
11852	Premium Support Plan (3 years max) For 11+ systems contact Customer Support at 435-753-1881				0
P/N	Maintenance Kit Option		Qty
20271	HCGG Twin	1335			0
20270	HCGG Single	550			0
20269	Classic	950			0
	Total cost of all items				0

Comments

Premium Support Plan Pricing

Standard Application Received May 1 - Oct 31 Price Per Unit	Discounted Application Received Nov 1 - Apr 30 Price Per Unit
$695	$345

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