Person to Contact ________________________________________________________

Company _______________________________________________________________

Address ________________________________________________________________

City _____________________ State/Province ______________ Postal Code _________

E-mail _________________________________________________________________

Phone _________________________________________________________________

Payment by Check: (SMI cannot bill you, please enclose payment.)

I have enclosed check # __________ in the amount of $___________________________

Payment by Credit Card:
Please charge my credit card - Visa MasterCard American Express

Card # ____________________________________ Exp Date _____________________

Card holder's name (please print) ____________________________________________

Card holder's signature (required) ____________________________________________