ORDER FORM

Com1 Software, Inc.
P.O. Box 482
Hudson, Ohio 44236                              TEL:(216) 653-3771
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                           PLEASE PRINT

           Name:__________________________________________________

 Address Line 1:__________________________________________________

 Address Line 2:__________________________________________________

           City:_______________________ State:____ Zip:___________

          Phone:(____)____-_______      Fax: (___)___-______
          Email:_______________________

        Contact:__________________________________________

      Signature:___________________________________ Date:___/___/_____

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QUANTITY      DESCRIPTION                         UNIT PRICE     TOTAL
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 _____  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  _________

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Place obtained from:___________________________________TEL:____________

            Version:______

   Type of computer:_________________________

   Type of practice:_____________________________________

Additional Comments:________________________________________________
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