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┌───────────────────────┐                                                      │Date:                  │                                  ▒▒▒▒▒▒▒▒▒▒▒▒▒▒▒▒▒▒▒ │                       │                                  ▒▒▒             ▒▒▒ │───────────────────────┤                                  ▒▒▒     FAX     ▒▒▒ │Time:                  │                                  ▒▒▒             ▒▒▒ │                       │                                  ▒▒▒ TRANSMITTAL ▒▒▒ ├───────────────────────┤                                  ▒▒▒             ▒▒▒ │Total Number of Pages: │                                  ▒▒▒▒▒▒▒▒▒▒▒▒▒▒▒▒▒▒▒ │                       │                                                      │                       │                                                      └───────────────────────┘                                                                                                                                     ┌─────────────────────────────────────────────────────────────────────────────┐│To FAX Number:  (Enter the number you are dialing)                           ││                                                                             ││                                                                             │├─────────────────────────────────────────────────────────────────────────────┤│Deliver To: (Enter the name of the person the transmittal should be given to)││                                                                             ││                                                                             │├─────────────────────────────────────────────────────────────────────────────┤│Company:                                                                     ││                                                                             ││                                                                             │├─────────────────────────────────────────────────────────────────────────────┤│Location:   (Enter the delivery address)                                     ││                                                                             ││                                                                             │├─────────────────────────────────────────────────────────────────────────────┤│Confirmation Requested:        ┌────┐            ┌────┐                      ││                               │    │ Yes        │    │ No                   ││                               └────┘            └────┘                      │└─────────────────────────────────────────────────────────────────────────────┘                                                                               ┌─────────────────────────────────────────────────────────────────────────────┐│From: (Name of Sender)                                                       ││                                                                             ││                                                                             │├─────────────────────────────────────────────────────────────────────────────┤│Company:                                                                     ││                                                                             ││                                                                             │├─────────────────────────────────────────────────────────────────────────────┤│Location: (Enter the sender's address)                                       ││                                                                             ││                                                                             │├─────────────────────────────────────────────────────────────────────────────┤│Phone Number:                                                                ││                                                                             ││                                                                             │├─────────────────────────────────────────────────────────────────────────────┤│From FAX Number:                                                             ││                                                                             ││                                                                             │└─────────────────────────────────────────────────────────────────────────────┘                                                                               MESSAGES:                                                                                                                                                     ───────────────────────────────────────────────────────────────────────────────                                                                               ───────────────────────────────────────────────────────────────────────────────                                                                               ───────────────────────────────────────────────────────────────────────────────                                                                               ───────────────────────────────────────────────────────────────────────────────                          Copyright 1989, CHiPS Inc.