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DO NOT EMAIL US
THIS FORM, For security reasons PLEASE USE A FAX
Declaration of Software Removal
and License Destruction
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Refund Case #:
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[Type the number that
you received from customer support ] |
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You need a Refund case number before we can process this form. Do Not Fax
to us this form unless you have received a Refund Case Number from SSI.
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To receive
a refund on a software
product you purchased from us, please complete this Declaration of Software Removal
and License Destruction. Be sure to include the reason you are requesting
a refund and sign where indicated.
In consideration of my receipt of
a refund, I ___________________________, (print your name) certify that:
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I have completely removed from all
computers all copies of the software products and licenses listed below;
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I have destroyed all paper and electronic
records of the software license & serial numbers for the software listed;
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I have not decompiled, reverse engineered
or reduced any portion of the software product to human perceivable form;
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I acknowledge that any continued use
of the software, license and/or serial numbers constitutes willful copyright infringement
and fraud for which I may be liable for criminal prosecution as well as civil damages
of up to $100,000.
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Credit Card Reversal
Form #:
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Credit Card Type |
_____________________________________________________________ |
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Credit Card Number |
_____________________________________________________________ |
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Exp. Date |
_____________________________________________________________ |
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Credit Card Security Code (Required)
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_____________________________________________________________ |
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I certify under penalty of perjury
that I am an authorized agent for the above company. I have personally read and
reviewed this declaration and it is true and correct to the best of my knowledge. |
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Signed: |
_____________________________________________________________ |
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Date: |
_____________________________________________________________ |
Fax to:
Serial Scientific International Inc,
Attn: Sales Department
Fax: (321) 282 1336 |
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DO NOT EMAIL US THIS FORM, For security reasons
PLEASE USE A FAX |
Instructions:
Copy the form above to your favorite word processor
, fill out the information and FAX it to us.
SSI is NOT responsible if you Fax this form to an erroneous
Fax Number
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