Zodiac Transcription

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Transcription Service Registration Form

Please provide information for all required fields.

= Required

Name

Company Name

Address

City

State

Zip *

Phone

Fax

Website

Required for New Sign up

Credit Card Number *

Expiration Date (mm/dd/yy)

Security Code

Name on the card

Payment Method:

Billed Services Monthly

Credit Card Authorization

Preferred Dictation Method
Toll Free Number
Digital Voice Recorder
Preferred Document Delivery Method
Please call to discuss
DockDesck (Preferred)
Fax *	:
Email	:
* Additional 10 Cents / Page

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Please charge the registration Fees $ 50.00 on my credit card (Required on Credit card)

I hereby authorize Zodiac Infotech to deduct monthly transcription service fees from my credit card mentioned above on 3rd of every month.

Yes, send me the Olympus DS-2 Digital voice recorder

No Charge, I agree to pay Min $ 125/- each user, each month for a period of 1 year.
I will pay $ 125.00 for DS-2.

I agree with transcription service sign up terms & conditions

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