 SOLO/GROUP BILLING SERVICE BILLING SYSTEM MODEL C1B3A210 ORDER FORM

 To obtain a registration file and the current version of the
 Model A210 on 3 1/2" diskette complete the following order form
 and send with check or money order to:
                                          COM1 SOFTWARE, INC.
                                          P.O. Box 482
                                          Hudson, Ohio 44236
                                          (216) 653-3771

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Company Name:__________________________________________________

Contact Person: _______________________________________________

Address Line 1:________________________________________________

Address Line 2:________________________________________________

City:_______________________ State:____ Zip:___________

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

Signature:___________________________________ Date:___/___/_____

Comments:________________________________________________
         ________________________________________________
         ________________________________________________

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QUANTITY      DESCRIPTION                         UNIT PRICE     TOTAL
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 _____  Registration for Model 210 ................$ 695.00   _________
                                        add 5.75% Sales Tax   _________

                                                      Total   _________
DO NOT WRITE IN THIS AREA
SYSTEM #: ____________
VERSION : ____________
MAILED   :___/___/____

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