BeMIS Scoring License - Order Form
Customer Information (name and address as on credit card, if using a credit card)
Last Name
First Name
MI
User Id (if assigned)
Email
Telephone
Address
City
State
Postal Code
Country
Order Information
Site Code
Order Number
Number of Tests to score	Cost per test     1 @ $15.75 2 to 9 @ $14.95 10 to 99 @ $13.90 100 to 249 @ $12.60 250 to 499 @ $11.00 500+ @ $9.25
Fee
Payment Information  Credit Card  Other
Credit Card Type	Select American Express Discover Master Card Visa
Number
Expiration Date	MM/YY
Security Code
Comment
The Authorization Code will be delivered by email within 1 business day.  Or, the Authorization Code will be immediately generated and displayed on-screen if you enter your password.   Password: