ORDER FORM Com1 Software, Inc. P.O. Box 482 Hudson, Ohio 44236 TEL:(216) 653-3771 -------------------------------------------------------------------- PLEASE PRINT Name:__________________________________________________ Address Line 1:__________________________________________________ Address Line 2:__________________________________________________ City:_______________________ State:____ Zip:___________ Phone:(____)____-_______ Fax: (___)___-______ Email:_______________________ Contact:__________________________________________ Signature:___________________________________ Date:___/___/_____ ----------------------------------------------------------------------- QUANTITY DESCRIPTION UNIT PRICE TOTAL ----------------------------------------------------------------------- _____ Model 170 Registration......................$ 79.00 _________ _____ Current Version 170 on 3.5 in floppy...... .$ 10.00 _________ _____ Printed Manual for Model 170................$ 30.00 _________ _____ Model 172 Registration .....................$129.00 _________ _____ Current Version 172 on 3.5 in floppy........$ 10.00 _________ _____ Printed Manual for Model 172................$ 30.00 _________ _____ Model 179 Registration .....................$195.00 _________ _____ Current Version 179 on 3.5 in floppy........$ 10.00 _________ _____ Printed Manual for Model 179................$ 30.00 _________ add 6.25% Sales Tax _________ Total _________ ----------------------------------------------------------------------- Place obtained from:___________________________________TEL:____________ Version:______ Type of computer:_________________________ Type of practice:_____________________________________ Additional Comments:________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________