form - Evan-Moor.com

❏ Purchase order enclosed ❏ Purchase Order # ________________

Billing Information

School/District Name _______________________________________________________________________

School/District Address ______________________________________________________________________

School/District City _________________________________________State _____Zip Code ______________

Purchasing Officer Contact Name (first and last) __________________________________________________

Purchasing Officer Phone ______________________________ Fax _________________________________

Purchasing Officer Email ____________________________________________________________________

If more than one school is purchasing interactive courseware and/or student licenses powered by Portals School, please include additional forms for each school.

School Information

School Name _____________________________________________________________________________

School Address ____________________________________________________________________________

School City ________________________________________________State ______ Zip Code ____________

Site License Manager Contact Name (first and last) ________________________________________________

(The Site License Manager will manage setting up teacher and student accounts.)

Site License Manager Phone__________________________ Fax ____________________________________

Site License Manager Email __________________________________________________________________

Will the Site License Manager use interactive courseware and student licenses? ___Yes ___No

Student Licenses ($5.99 each per student per year)

Number of Students _____________________ Student License Activation Date ________________________

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Email:portalsschool@evan-moor.com Fax:1-800-777-4332

Mail:Evan-Moor Educational PublishersAttn: Portals School Purchase Order18 Lower Ragsdale DriveMonterey, CA 93940-5746

Please complete this form and submit it with your purchase order for interactive courseware and/or student licenses powered by Portals School.

Interactive Courseware ($199.99 each per school account, perpetual license)

A Word A Day Daily Geography Practice

❏ Grade 1 ❏ Grade 1

❏ Grade 2 ❏ Grade 2

❏ Grade 3 ❏ Grade 3

❏ Grade 4 ❏ Grade 4

❏ Grade 5 ❏ Grade 5

❏ Grade 6 ❏ Grade 6

Daily Language Review Daily Reading Comprehension

❏ Grade 1 ❏ Grade 1

❏ Grade 2 ❏ Grade 2

❏ Grade 3 ❏ Grade 3

❏ Grade 4 ❏ Grade 4

❏ Grade 5 ❏ Grade 5

❏ Grade 6 ❏ Grade 6

❏ Grade 7 ❏ Grade 7

❏ Grade 8 ❏ Grade 8

Daily Science Daily Word Problems: Math

❏ Grade 1 ❏ Grade 1

❏ Grade 2 ❏ Grade 2

❏ Grade 3 ❏ Grade 3

❏ Grade 4 ❏ Grade 4

❏ Grade 5 ❏ Grade 5

❏ Grade 6 ❏ Grade 6

Look, Listen, & Speak

❏ At Home

❏ At School

❏ Keeping Healthy

❏ My Community

❏ My Family & Me