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Step 1: Customer Information

Please complete the following information about yourself. An e-mail will automatically be sent to the e-mail address identified below confirming receipt of your information.

This information is used strictly for the records of Holland Bloorview Kids Rehabilitation Hospital, Quillsoft Ltd., and distributor Strategic Transitions and its distribution associates and is not shared with anyone else. It enables us to follow-up with you regarding WordQ software.

*Indicates required information

If you do not have highspeed Internet access, you may request a demo CD to be mailed to you (US and Canada only).

*First name
*Last name
Title
Organization
Department
*Address 1
Address 2
*City/Town
*Province/State
*Country
*Postal Code/Zip
*Telephone
Fax
*E-mail
*End use



1.	Predict it
2.	Hear it
3.	Choose it
4.	Review it
5.	Correct it
6.	Write it now

Developed through research at
Holland Bloorview Kids Rehabilitation Hospital