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e-DECA Customer Profile

Thank you for taking the time to complete the attached customer order profile. Before completing this online form, it is critically important that you understand and have access to the hardware and software necessary to effectively use the e-DECA. If you have not already reviewed these requirements, please click here to view the system requirements.

* Required Fields

Primary Administrator & Organization Contact Information

Contact Information:

Name:

First Required	Middle Required	Last Required

Email: Required

Street 1:

Street 2:

City/State/ZIP:

City Required	StateRequired	ZIPRequired

Phone Number: Required

Employer: Required

Yes, I would like to receive e-mail from Devereux

Email Format:

Note: (If opting in above, you will receive updates from Devereux Treatment Facilities.)

Additional Administrators (if YES, please add their name, phone and email)

(Maximum response 255 chars, approx. 5 rows of text)

*3.

Number of Annual Licenses Purchased:

*4.

Purchase Format (By Child or By Rating):

*5.

Number e-DECAs Purchased: (If by child option was selected above, then insert the number of children ; if by rating was selected, multiply the number of packages purchased by 40)

Purchase Order Number:

Invoice Total:

Preferred date: (Please provide 2 dates for e-DECA set up. This entails a phone call lasting approximately 1 hour. The primary administrator will be contacted to confirm set-up. Every effort will be made to accommodate a requested date.)

Please check the most appropriate response:
Our agency has been using the paper version of the assessment form and is now converting to the web-based version
Our agency has not used the DECA Program in the past

Technological Information:

10.

Operating System:

(Select one of the available choices or enter a different value.)

11.

Mode of Internet Access:

(Select one of the available choices or enter a different value.)

12.

Internet Browser:
e-Deca requires that customers use Internet Explorer. Please check here to confirm your browser is Internet Explorer.

13.

Adobe Acrobat:
e-Deca requires that customers have Adobe Acrobat. Please check here to confirm you have Adobe Acrobat installed on your computer.

14.

If your program has an individual responsible for assisting with technological issues, please provide the person's name, phone & eMail.

(Maximum response 255 chars, approx. 5 rows of text)

If you have questions about any of the information requested, please call the Devereux e-DECA support line at 866- 872-4687.