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  1.  
  2. +------------------------------------------------------------------------------+
  3. |                         Note by Note - Order Form                            |
  4. |                                                                              |
  5. |          Applied MicroSystems, Inc.   Roswell, GA    (404) 552-9000          |
  6. +------------------------------------------------------------------------------+
  7. |                                        | Qty. |      at       |              |
  8. |                                        +------+---------------+--------------+
  9. |                 Note by Note           |      | $  69.95 each | $            |
  10. |                                        +------+---------------+--------------+
  11. |                                                    sub-total  | $            |
  12. |                                                               +--------------+
  13. |                         GA residents please add 6% sales tax  | $            |
  14. |                                                               +--------------+
  15. |                                     Shipping / handling $5.00 |              |
  16. |                           (not required if pre-paid by check) | $            |
  17. |                                                               +--------------+
  18. |                                                        TOTAL  | $            |
  19. |                                                               +--------------+
  20. |                                                                              |
  21. |      Please specify diskette size:   ( ) 5¼"    ( ) 3½"                      |
  22. |                                                                              |
  23. |                                                                              |
  24. |      Mail to:   Applied MicroSystems, Inc.                                   |
  25. |                 Attn:  Dept. NW                                              |
  26. |                 P.O. BOX  832                                                |
  27. |                 Roswell, GA  30077                                           |
  28. |                                                                              |
  29. |                                                                              |
  30. |  Please make checks payable (in U.S. funds) to Applied MicroSystems, Inc.    |
  31. |                                                                              |
  32. |                                                                              |
  33. |  Method of Payment:  ( ) pre-paid by check   ( ) Visa   ( ) MC   ( ) AMEX    |
  34. |                                                                              |
  35. |   Credit Card Info:             Name:_____________________________________   |
  36. |                                                                              |
  37. |                             Acct. No:_____________________________________   |
  38. |                                                                              |
  39. |                           Expiration:_____________________________________   |
  40. |                                                                              |
  41. |                            Signature:_____________________________________   |
  42. |                                                                              |
  43. |   Ship To:       Name:_____________________________________                  |
  44. |                                                                              |
  45. |               Company:_____________________________________                  |
  46. |                                                                              |
  47. |               Address:_____________________________________                  |
  48. |                                                                              |
  49. |                       _____________________________________                  |
  50. |                                                                              |
  51. |                  City:_____________________________________                  |
  52. |                                                                              |
  53. |                 State:_____________    Zip:________________                  |
  54. |                                                                              |
  55. |             Telephone:_____________________________________                  |
  56. |                                                                              |
  57. |                                                                              |
  58. +------------------------------------------------------------------------------+
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