EDI Subscription 703-879-6590

Sidereal Corporation

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Sidereal EDI/FACNET Subscription

Please type in the requested information on this form and:
(1) print the form,
(2) fax a signed copy to Sidereal Corporation on (703) 941-6904
(3) mail original to Sidereal at 85 South Bragg Street, Suite 200-M, Alexandria, VA 22312.

Name

Title

Organization

Street address

Address (cont.)

City

State/Province

Zip/Postal code

DUNS #

CAGE Code

Phone

FAX

Email

Choose one of the following Federal Supply Classification Groups.

Choose one of the following Federal Supply Classification Groups.

Choose one of the following Federal Supply Classification Groups.

Choose one of the following Federal Supply Classification Groups.

Choose one of the following Federal Supply Classification Groups.

Additional Comments:

I authorize Sidereal Corporation to charge my credit card an initial fee of $140.00 ($80.00 Start-up + $60.00 Basic Monthly Charge) and a monthly fee of $60.00 per month. Charges should be made to the credit card described below.

(If you prefer may may call in your credit card information to Sidereal on 703-879-6590)

BILLING

Credit card

Cardholder name

Card number

Expiration date

Enter today's date : -- mm/dd/yy

Signature _______________________________

By signing this form, the subscriber acknowledges reading, understanding and agreeing to the terms of the Sidereal Corporation EC/EDI Services Agreement.

Please (1) print the form, (2) fax a signed copy of the form to Sidereal Corporation at (703) 941-6904 and (3) mail the original to Sidereal at 85 South Bragg Street, Suite 200-M, Alexandria, VA 22312.