ASQ Online Annual Subscription Account Setup

• Please fill out the following form completely. All requested information must be supplied before we can set up your ASQ Online annual subscription.

NOTE: You must have a pending ASQ Online Annual Subscription order number to complete this form.

• ASQ Online Order Info

• ASQ Online Order Number (e.g. Purchase Order, Web Confirmation, Invoice)**

• ASQ Online Annual Subscription Service Requested* Subscription Service ASQ Pro (single-site service) $149.95 annually ASQ Enterprise (multi-site service) $499.95 annually

• Account / Program Details

• Program Country* Country United States Canada Afghanistan Åland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darrussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos Islands Colombia Comoros Congo, Democratic Republic of the Congo, Republic of the Cook Islands Costa Rica Côte d'Ivoire Croatia Cuba Curaçao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini (Swaziland) Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine, State of Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Réunion Romania Russia Rwanda Saint Barthélemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Islands Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay US Minor Outlying Islands Uzbekistan Vanuatu Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe

• Program Name*

• Program Address Line 1*

• Program Address Line 2

• Program City*

• Program State* State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific

• Program Province* Province Alberta British Columbia Manitoba New Brunswick Newfoundland & Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon

• Program State (Intl.)*

• Program Zip/Postal Code*

• Program Phone Number*

• Subscription Administrator Details

The Subscription Account Administrator designated below will be the individual to receive the initial welcome/login email to set up your program’s ASQ Online annual subscription. This person can set up other users and designate roles (including other Account Administrators), as well as set up program information, and child profiles, etc.

• Subscription Administrator Name*

• Subscription Administrator Phone*

• Email*

• Choose Your Subscription Start Date!

ASQ Online annual subscriptions may only start on the 1st, 5th, 10th, 15th, 20th, or 25th of any given month. If you select a start date that falls on a weekend or holiday, access will be granted the following business day. Same day startups are not possible. Please select an applicable FUTURE start date for your subscription.

• Subscription Start Date* Month January February March April May June July August September October November December

• Subscription Start Date Jan* Date 5th 10th 15th 20th 25th

• Subscription Start Date Dec* Date 1st 5th 10th 15th 20th

• Subscription Start Date* Date 1st 5th 10th 15th 20th 25th

• Terms and Conditions

• By checking here and submitting this form, I certify that I understand:*

  • A unique ASQ keycode for EACH set of Questionnaires, and for each physical site, is required to access those Questionnaires in my ASQ Online Subscription. e.g. If I wish to screen using ASQ-3 English Questionnaires at one physical site and with ASQ:SE-2 Spanish Questionnaires at two physical sites, I will need one ASQ-3 English Keycode and two ASQ:SE-2 Spanish Keycodes. These keycodes are only located inside the physical set of applicable ASQ Questionnaires (separate purchase is required for all necessary physical print product/keycodes).

• By checking here and submitting this form, I certify that:*

  • I own all of the required physical ASQ Questionnaires required for my ASQ Online subscription.

• By checking here and submitting this form, I certify that I understand:*

  • ASQ Online is an “opt-out” subscription, meaning this subscription will automatically renew each year unless the customer informs vendor (Brookes Publishing) of intent to cancel prior to the start of a new subscription year. ASQ Online Annual Subscription fees are invoiced each year in advance and are payable prior to your subscription renewal date. Customers will receive a renewal invoice notice via USPS mail approximately 90-days prior to the end of the annual subscription period.

• By checking here and submitting this form, I certify that I understand:*

  • ASQ Screens are billed annually in arrears based on actual screen usage at the end of the subscription year. The annual screening usage statement may vary and will be billed according to the actual number of screens used at $0.50 for each Screen completed. This usage fee is separate, and above and beyond, the annual subscription service fee.

• Electronic Signature and Job Title*
  Please type your name and job title. Typing your name here constitutes your signature and agreement to begin your annual ASQ Online subscription with the details provided herein and subject to the Terms & Conditions.

• Comments and Questions

• Do you have any additional comments or info you’d like to share?