                    PRODUCT LINE ORDER FORM

 To obtain a registration file and the current version of any
 of the following described software products on 3 1/2" diskette,
 complete this order form with appropriate credit card information or
 send with check or money order to:

                       COM1 SOFTWARE, INC.
                       P.O. Box 482
                       Hudson, Ohio 44236
                       (216) 653-3771
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              ************CREDIT CARD INFORMATION************

Type of Card  _____ Visa  _____ MC  _____ AMEX        
Card No. _________________________      Total Purchase $ _______   
Expiration Date _________

Signature: _______________________
              ************************************************

Name  ________________________________________________________
           (As it appears on the credit card)

Company _______________________________________________________

Address Line1 ___________________________________________________
                        (Billing Address for credit card)

Address Line2 :________________________________________________________

City, State, Zip :_____________________________________________________

Phone ____________________________ Email Address _____________________

Additional Information:
__________________________________________________________________________________________________________________________________________________

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QUANTITY      DESCRIPTION                         UNIT PRICE     TOTAL
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 _____ Model 170 Solo Claim Entry System........... $ 79.00   ________
 _____ Model 179 Group Claim Entry System.......... $195.00   ________
 _____ Model 199 Billing Service Claim Entry System $349.00   ________
 _____ Model 166 Solo Billing System............... $279.00   ________
 _____ Model 136 Group Billing System.............. $495.00   ________
 _____ Model 202 DME Billing System................ $495.00   ________
 _____ Model 210 Billing Service Billing System.....$695.00   ________
                                        add 5.75% Sales Tax   ________

                                                      Total   ________
