Order 1 of 3 Ways

1. Print this form and mail it with your check, credit card info, or money order. 2. Print this form and fax it (include credit card info). 3. Telephone Tom Scott at (770) 457-1223. Dot Matrix Printer Form THANK YOU FOR YOUR ORDER

I am ...  a Medicare beneficiary  a Medicare beneficiary and caregiver  an adult-child caregiver  a grandchild  a volunteer I am ordering ...  Windows 95 - Standard Version  Windows 3.1 - Standard Version  Windows NT - Standard Version  Macintosh - Standard Version Name  Street Address  City   State or Province   Zip code   Day Telephone   Night Telephone   Email Address   Credit Card  Card Number  Expiration Date  Signature  Make check or money order payable to: Tom Scott Enterprises, Inc. 2109 Seaman Circle, NE Atlanta, GA 30341-1523 Please allow 4-6 weeks for delivery.