SUBMISSION FORM "PROVIDING EXPERT SERVICES IN HOME/OFFICE TECHNOLOGY" PC Repair In-home Service Software Installation Hardware Installation Network/Computer Upgrades DSL Installation Database Design Website Design/Hosting Custom Design Software Implement BackUp/Recovery Plans Please fill out the following form in regards to the desired work to be performed. (Form will be promptly submitted for a price quote) Full Name: (required) E-mail address: (required) Company Name: Billing Address: City: State: Zip Code: - Phone (required) Fax Date Please describe nature of work in the box provided

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Tellap Direct Solutions, 1 North 272 Purnell Street, Carol Stream, IL 60188-2363, info@tellap.com