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  1.                                    ORDER FORM
  2.  
  3.  Name: ______________________________________________
  4.  
  5.  Company: ___________________________________________
  6.  
  7.  Address: ___________________________________________
  8.  
  9.  City: ______________________________ State: ________
  10.  
  11.  Zip code: _____________________
  12.  
  13.  Phone: _____________________________  Ext: _________
  14.  
  15.  Product                          Quanity          Price/each       Total
  16. ------------------------------------------------------------------------------
  17.  
  18.  MSECURE Server Version          _______      x       $195    =    _________
  19.  The Secure Screen Saver
  20.  
  21.  6 months FREE upgrades included
  22.  Site licensing is also available. Call for details.
  23.  
  24.                                         ---------------------------------------
  25.                   [2-day Express Mail]   Shipping and Handling ($5)
  26.                                          (Fed Ex available for $15)
  27.                                          (COD Charge add $10)       _________
  28.     
  29.                                          Tax (VA residents add %4): _________
  30.  
  31.  
  32.                                          Total order:               _________
  33.  
  34.                           [All orders shipped on 3-1/2"]
  35.  
  36. How do you wish to pay for your order:
  37.  
  38.        Purchase Order _______        Check _________        COD _____________
  39.  
  40.        Visa __________   Account Number:  ___________________________________
  41.  
  42.                          Expiration Date: _________________
  43.  
  44. Additional information:
  45.  
  46.         What version Netware are you running? ______________
  47.  
  48. Please return form to:
  49.  
  50.         Dana Consultants
  51.         PO Box 2953                            (800) 800-9301
  52.         Reston, VA 22091
  53.