Credit
cards and checks accepted. Please make checks payable
to Core Documents, Inc. Use one of these three options
to pay for and finalize your order: |
| |
| 1.
Proceed to our secure on-line payment form. |
2.
Print this page, complete the credit card section, and
fax the form to |
| Core
Documents at (941)795-4802 . |
3.
Print and fax this page with a copy of your check to Core
Documents at (941)795-4802 . |
| We
can process your check with a copy of the original via E-Commerce. |
| |
| ***
Shipping and Handling charge of $15.00
has been automatically added to this order. |
| |
|
| |
Package Requested: Section<%pack%>, COST INCLUDES SHIPPING
& HANDLING: $<%shipping%> |
| ---------------------------------------------------------------------------------------------------------- |
| ORDER INCLUDES SHIPPING & HANDLING TOTAL: $<%shipping%> |
| ---------------------------------------------------------------------------------------------------------- |
Purchaser
Information
|
| First Name |
<%pfirstname%>
|
| Last Name |
<%plastname%>
|
| Company |
<%pcompany%>
|
| Address |
<%paddress%>
|
| City |
<%pcity%>
|
| State |
<%pstate%>
|
| Zip Code |
<%pzip%>
|
| Phone |
<%pphone%>
|
| Fax |
<%pfax%>
|
| E-Mail |
<%pemail%>
|
|
| |
Employer
Information For Documents
|
| First Name |
<%efirstname%>
|
| Last Name |
<%elastname%>
|
| Company |
<%ecompany%>
|
| Address |
<%eaddress%>
|
| City |
<%ecity%>
|
| State |
<%estate%>
|
| Zip Code |
<%ezip%>
|
| Phone |
<%ephone%>
|
| Fax |
<%efax%>
|
| E-Mail |
<%eemail%>
|
|
| |
| Form
of Business:
<%business%>
|
|
Employer
Federal ID#:
<%efid%>
, State
of Inc.:
<%esinc%>
, Number
of Employes:
<%empno%>
|
|
Legal
name(s) of affiliated company(ies) that will be covered by
the plan:
- <%leg1%>
- <%leg2%>
- <%leg3%>
- <%leg4%>
|
|
Name
of Plan Administrator: (Employer unless otherwise listed)
|
| Name |
<%aname%>
|
| Address |
<%aadd%>
|
| City |
<%acity%>
|
| State |
<%astate%>
|
| Zip Code |
<%azip%>
|
| Phone |
<%aphone%>
|
|
| |
|
Types
of Benifits plans to be offered
<%benefitplans%>
|
| Effective
Date : A New plan effective date as of (date)
<%efdate%>
|
|
Plan year - The
first plan year will be: a) A 12 consecutive month period
begining (date) <%sdate%> and ending (date)
<%efdate%> |
| Eligibility
requiements: All employees who will work
more than
<%elig%>
hours per week |
| Waiting
Period: Employees can participate the
first day of the month following
<%wtprd%>
days
of Employments |
Plan
Option :
<%planoption%>
|
| |
Note:
<%notes%>
|
|
| |
| |
| If
faxing your order and paying by credit card, please
complete the following information after printing this page.
|
| |
|
|
|
|
|
Card Type: |
VISA |
Master Card |
Discover |
American Express |
|
Card Number:
______ _____ _____ _____Expiration Date: ___/___/_____ |
|
Name as it
appears on card: _____________________________________ |
| Card
billing address for verification purposes: |
| Address:______________________________________________________ |
| City___________________State__________________Zip
Code_________ |
| |
|
Signature_______________________ Date___/___/_____ |
|
|
