<p> Subscription Group Order Form</p><p> Special Group Order: we would like to order one or more licenses to UpToDate, based on the specifications below. PDA software is Windows only and free with an individual subscription.</p><p>Name Speciality </p><p>Institute </p><p>Address City Zip/Postal Code </p><p>Country Date (of subscription request) </p><p>Multi-User Subscription Options  Multiple Copies: see specification below (…... x) $ ______ Shipping & Handling - Outside North America ( …... X $ 35,00) $ ______</p><p>Total $ ______</p><p>Specification Name Trainee PDA Renewal Subscriber ID if renewal / Yes / No Yes / No Yes / No Remarks</p><p> Will be paid in advance after invoice  Will be paid in advance by check Please send a pro – forma invoice to us in advance Please send a pro – forma invoice to us in advance </p><p> Will be paid by credit card. Please send a pro – forma invoice afterwards</p><p>Credit Card Number: Exp. Date: </p><p>Name of the Card Holder: </p><p>Signature </p><p>UpToDate Inc, 95 Sawyer Road, Waltham, MA 02453 – 3471, USA Phone: +1 781 392 2000 Fax: +1 781 642 8840 www.uptodate.com International Office: tel +31 79 3716143 / fax +31 79 3716177</p>