====================================================    REHABTOOL.COM - ValueSearch(TM) - ORDER FORM==================================================== 1. Complete this order form and send it to us by     email, fax, or postal mail. 2. Mail us your payment of $199.00 in the form of a     Money Order, Cashier's Check, or Certified Check     (U.S. funds, drawn on a U.S. bank), made payable     to "RehabTool.com".    Email:   ValueSearch@rehabtool.com    Fax:     (1) 281-531-6406    Address: RehabTool.com             P.O. Box 572190             Houston, TX 77257             USA     NOTE: Your order will be processed upon receipt of  your check or money order. For faster service, we  suggest making your payment by credit card from our  secure website. It's the quickest and safest way to  purchase online and expedite your order. We accept  all major credit cards. To pay by credit card, go to http://www.rehabtool.com/search/valuesearchorder.html====================================================1. WHAT ARE YOU LOOKING FOR?====================================================Describe your needs, requirements, whishes, constraints, barriers, etc.====================================================2. DESCRIBE THE DISABILITY, IMPAIRMENT, OR CONDITION   OF THE PERSON NEEDING THE TECHNOLOGY OR PRODUCT========================================================================================================3. WHAT TASKS SHOULD THE TECHNOLOGY OR PRODUCT HELP   ACCOMPLISH OR PERFORM?=======================================================================================================4. DESCRIBE THE ENVIRONMENT IN WHICH THE TECHNOLOGY   OR PRODUCT WILL BE USED======================================================================================================5. TELL US ABOUT YOURSELF===================================================Your Full Name:Your Email Address:Your Phone Number:Your Home/Work Address:Would you like to receive our FREE quarterlyAssistive Technology newsletter? [Y/N]===================================================NEED ASSISTANCE OR HAVE A QUESTION?===================================================Don't hesitate to contact us! Our dedicated team isavailable to answer your questions. For questions aboutsearches, contact search@rehabtool.com. For orderingor payment questions, contact sales@rehabtool.com.For more information about our Product Search & Referralservices, visit http://www.rehabtool.com and choose "Find a Product".Thank you for ordering our services. We look forward tohelping you find the best technology for your needs.