DASI eCLINIC - Register

New client
Plan Basic

1 Service’s characteristics

2 Client’s data

3 Payment gateway

4 Payment confirmation

Payment’s frequency

Plan

Users

1

Activation date

Renewal date

Coupon Code

Price/30 days:

0

€

Total:

0

€
Taxes not included

Discount according to licences no.

Licences no.	Discount
1-1000	0%

Discounts according to payment frequency

Payment’s frequency	Discount
30 Days	0%
90 Days	0%
180 Days	0%
360 Days	15%

1 Service’s characteristics

2 Client’s data

3 Payment gateway

4 Payment confirmation

Country

Client’s type ∗	ParticularCompany
Contact person :
Name ∗
First surname ∗
Second surname
Company name ∗
Number of the document ∗
Intercommunity VAT
Phone number
E-mail∗
User∗
Password∗
Repeat password∗	Password correct
User’s language
Security question
Security answer∗
Accept Terms of use
I do authorize the sending of informative electronic communications regarding activities, products or services by email.

Pagar con tarjeta o PayPal :

Card

PayPal

Remember the card for future payments. notice

notice

1 Client’s data

2 Service’s characteristics

3 Payment gateway

4 Payment confirmation

Tipodocumento

Nombrecentro

Centrocif

Centrotipodocumento

Centrodireccio

Centrodireccio2

Centrotelefono1

Centrotelefono2

Idiomacentro

Time zone

Date format

Summary

Plan price (

):

€ every 30 days
Users:

Payment’s frequency:

Import:

€

Disc payment frequency (

%):

€

Total without taxes:

€
Tax import (

%):

€

TOTAL:

€