Supra Corporation

                           MODEM ORDER FORM

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  |                       PERSONAL INFORMATION                          |
  |                                                                     |
  | Name:________________________________   Phone:_____________________ |
  | Company:_____________________________   FAX:_______________________ |
  | Address:_____________________________   BBS:_______________________ |
  | City:________________________________   ___________________________ |
  | State:_______________________________                               |
  | Country / Province:__________________                               |
  | Zip:_______________                                                 |
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  |                         ORDER INFORMATION                           |
  |                                                                     |
  |  Date_________________  Order #_____________  Cust PO#_____________ |
  |  BILL TO:__________________________________________________________ |
  |  Address:__________________________________________________________ |
  |  City:________________________ State:__________ Zip:_______________ |
  |  Country / Province:___________________________                     |
  |  Contact Name:_____________________________________________________ |
  |  SHIP TO:__________________________________________________________ |
  |  City:________________________ State:__________ Zip:_______________ |
  |  Country / Province:___________________________                     |
  |  Referred by:______________________________________________________ |
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  |                     PRODUCT INFORATION                              |
  |                                                                     |
  |  Item:______________________________________                        |
  |  Part #_____________________ (Please refer to Retail Price Lists)   |
  |  Price:_____________________ Qty:______________                     |
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  |  SHIPPING:               QTY:   BILLING:                            |
  |  __ Ground      $ 8.00/pc ___   __ Visa:___________________________ | 
  |  __ Blue Label  $14.00/pc ___   __ M.C. ___________________________ |
  |  __ Red Label   $30.00/pc ___           Exp. Date:_________________ |
  |  __ CANADA Mail $16.25/pc ___   __ Cashiers Check (COD $5.00 charge)|
  |  __ CANADA Exps $43.25/pc ___   __ Pre-Pay  (No Personal Checks)    |
  |                                                                     |
  |  INTERNATIONAL:                  QTY:                               |
  |  __ FedEx 1st piece    $90.00    ___                                |
  |  __ Additional pieces  $20.00    ___                                |
  |                                                                     |
  |  TOTAL COST:_________________                                       |
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  |  COMMENTS:                                                          |
  |  __________________________________________________________________ |
  |  __________________________________________________________________ |
  |  VERIFIED BY:__________________________  DATE:_____________________ |
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  Please fill out and send or FAX to Supra. (Do not upload to this board).