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  1.                             ANSI SHOPPE Order Form
  2.               [ Please print this form and fill out completely ]
  3.  
  4.  
  5.  Name ____________________________________________________________
  6.  
  7.  Address _________________________________________________________
  8.  
  9.  City ____________________________  State ______  Zip ____________
  10.  
  11.  
  12.  Please send me the following items:
  13.  
  14.   Package # |     Item                   | Quantity    | Price ea | Total
  15.  -------------------------------------------------------------------------
  16.             |                            |             |          |
  17.  -------------------------------------------------------------------------
  18.             |                            |             |          |
  19.  -------------------------------------------------------------------------
  20.             |                            |             |          |
  21.  -------------------------------------------------------------------------
  22.             |                            |             |          |
  23.  -------------------------------------------------------------------------
  24.             |                            |             |          |
  25.  -------------------------------------------------------------------------
  26.             |                            |             |          |
  27.  -------------------------------------------------------------------------
  28.   Total -------------------------------------->         ------------->
  29.  
  30.  
  31.  [Check One]: I'm enclosing the following size disk(s) for my order:
  32.  
  33.  ___ 5 1/4" 360k   ___ 5 1/4" 1.2mg    ___ 3 1/2" 720k   ___ 3 1/2" 1.44mg
  34.  
  35.  ___ No Disk Enclosed, Please supply 360k Disk(s). {If you chose this
  36.      option please refer to the second price column in ANSISHOP.DOC. Note:
  37.      When chosing this option, each package will be placed on a separate
  38.      disk.}
  39.  
  40.  NOTE: List catalogs (as listed in ANSISHOP.DOC) as Price: N/A.  For quotes
  41.  on Custom Art and for Catalogs, please enclose a Self-Addressed Stamped
  42.  Envelope.  Make all checks/Money Orders payable to:
  43.  
  44.                          Lora L. Ruffner
  45.  
  46.  Mail this form, along with your payment to:
  47.  
  48.                          Lora L. Ruffner
  49.                          Third Stage Software Development Corporation
  50.                          PO Box 3164
  51.                          St. Charles, MO 63302-3164
  52.  
  53.  Enclose any other information you feel we may need on a separate sheet.
  54.  Please refer to ANSISHOP.DOC for a complete list of products, services,
  55.  and fees.