Please print this form and fax to 217-897-8023 or mail to

The following organization hereby applies for an open account with Data Comm for Business, Inc. (Hereafter "DCB"). The applicant understands and agrees that if granted an open account by DCB that all charges against the account will be paid in full within 30 days of the invoice date. If any charges are not paid in 30 days, a late fee of 1 1/2 % per month will be assessed against the outstanding balance over 30 days old.

Date:
Company:
Contact Person:
Address:
City:	State:	Zip:

Accounts Payable Contact:	Phone:
Purchasing Contact:	Phone:

Bank References
Bank:
Contact Name:	Phone:
Bank:
Contact Name:	Phone:
Trade References
Company:
Contact Name:	Phone:
Company:
Contact Name:	Phone:
Company:
Contact Name:	Phone:

If you are in a hurry, remember that we also accept Visa, American Express, and MasterCard.

Data Comm for Business Inc. 2949 County Road 1000 E Dewey, Il 61840	Voice: 217-897-6600 Toll Free: 800-4-DCB-NET Toll Free: 800-432-2638	Email: Contact Page Web: www.dcbnet.com Fax: 217-897-8023
All DCB web pages copyright ©1995- Data Comm for Business, All rights reserved. EtherPath®, EtherSeries®, EtherPoll®, EtherBridge® and EtherModem® are Registered Trademarks of Data Comm for Business, Inc.