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                               DimVESA Order Form
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  Name:_____________________________________________________________________

  Company:__________________________________________________________________

  Mailing Address
    Street        :_________________________________________________________

    City          :_________________________________________________________

    State/Zip Code:_________________________________________________________

    Country       :_________________________________________________________

  Voice Number    :_________________________________________________________

  Facsimile Number (optional):______________________________________________
  __________________________________________________________________________
  System Info (optional) to aid us in supporting you, should problems arise

    CPU Type (286/386/486/Pentium/Pentium Pro, etc.) :______________________

    System Speed (33MHz, 50MHz, 66MHz, etc.) :______________________________

    Total System RAM (8MB, 16MB, 32MB, etc.) :______________________________

    Hard Disk Size (320MB, 840MB, 1.2GB, etc.) :____________________________

    Monitor :_______________________________________________________________

    Graphics Card :_________________________________________________________

  DimVESA site license for 15 computers (minimum)     ($15.00 US) $___15.00_
      (includes shipping, free of charge)

  Each additional computer is $0.75 US dollars more --    Amount: $_________

  If you would like a diskette with the newest version,
  please add $5.00 US dollars  --            ($5.00 US, optional) $_________


             Signature:__________________________________  Total: $_________


  Mail (with payment) to:
                            Alexander C. Eremeef (Rurik)
                            P.O. BOX 393
                            Watertown, MA  02272-0393
                            U.S.A.

  Please allow 28 days for delivery.