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All requested information must be supplied before we can set up your ASQ Online annual subscription. **NOTE: You _must_ have a pending ASQ Online Annual Subscription order number to complete this form.** - ## ASQ Online Order Info - ASQ Online Order Number (e.g. Purchase Order, Web Confirmation, Invoice)\*\* - ASQ Online Annual Subscription Service Requested\* Subscription ServiceASQ Pro (single-site service) $149.95 annuallyASQ Enterprise (multi-site service) $499.95 annually - ## Account / Program Details - Program Country\* CountryUnited StatesCanadaAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe - Program Name\* - Program Address Line 1\* - Program Address Line 2 - Program City\* - Program State\* StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific - Program Province\* ProvinceAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon - Program State (Intl.)\* - Program Zip/Postal Code\* - Program Phone Number\* - Program Phone Number\* - ## Subscription Administrator Details The Subscription Account Administrator designated below will be the individual to receive the initial welcome/login email to set up your program’s ASQ Online annual subscription. This person can set up other users and designate roles (including other Account Administrators), as well as set up program information, and child profiles, etc. - Subscription Administrator Name\* - Subscription Administrator Phone\* - Subscription Administrator Phone\* - Email\* - ## Choose Your Subscription Start Date! ASQ Online annual subscriptions may only start on the 1st, 5th, 10th, 15th, 20th, or 25th of any given month. If you select a start date that falls on a weekend or holiday, access will be granted the following business day. **Same day startups are not possible.** Please select an applicable **FUTURE** start date for your subscription. - Subscription Start Date\* MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember - Subscription Start Date Jan\* Date5th10th15th20th25th - Subscription Start Date Dec\* Date1st5th10th15th20th - Subscription Start Date\* Date1st5th10th15th20th25th - ## Terms and Conditions - By checking here and submitting this form, I certify that I understand:\* - [ ] A unique ASQ keycode for EACH set of Questionnaires, and for each physical site, is required to access those Questionnaires in my ASQ Online Subscription. e.g. If I wish to screen using ASQ-3 English Questionnaires at one physical site and with ASQ:SE-2 Spanish Questionnaires at two physical sites, I will need one ASQ-3 English Keycode and two ASQ:SE-2 Spanish Keycodes. These keycodes are only located inside the physical set of applicable ASQ Questionnaires (separate purchase is required for all necessary physical print product/keycodes). - By checking here and submitting this form, I certify that:\* - [ ] I own all of the required physical ASQ Questionnaires required for my ASQ Online subscription. - By checking here and submitting this form, I certify that I understand:\* - [ ] ASQ Online is an “opt-out” subscription, meaning this subscription will automatically renew each year unless the customer informs vendor (Brookes Publishing) of intent to cancel prior to the start of a new subscription year. ASQ Online Annual Subscription fees are invoiced each year in advance and are payable prior to your subscription renewal date. Customers will receive a renewal invoice notice via USPS mail approximately 90-days prior to the end of the annual subscription period. - By checking here and submitting this form, I certify that I understand:\* - [ ] ASQ Screens are billed annually in arrears based on actual screen usage at the end of the subscription year. The annual screening usage statement may vary and will be billed according to the actual number of screens used at $0.50 for each Screen completed. This usage fee is separate, and above and beyond, the annual subscription service fee. - Electronic Signature and Job Title\* Please type your name and job title. 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