This is the U.S. MAIL AND FAX HIPAA ORDER FORM

This is the Mail and/or Fax order form for your HIPAA Needs - Use this to order by U.S. MAIL or by FAX

FOR FASTEST SERVICE, GRAB YOUR PHONE AND CALL (702) 735-0503

CALL NOW TO ORDER BY CREDIT CARD - PHONE 702.735.0503

Use this handy order form to order either The "Complete Instant HIPAA Security Kit in a Box"or individual HIPAA Security Products shipped to you by FAST U.S. Priority Mail - Delivery Confirmation.

You can order by MAIL using your check, credit card or money order. You can order by FAX using your check or credit card. For faster ordering, call to place your order by phone: 702-735-0503 during office hours, Pacific Time Zone.

To order by U.S. MAIL or FAX, Please print out this order form (printer icon, or File, Print from your top menu bar) then complete it. To order by e-mail using your credit card, see instructions at bottom of this page.

Please PRINT neatly or Type:

Your Name: ___________________________________________________

Street Address:_________________________________________________

City:_________________________________________________________

State:___________________________________ Zip:__________________

Day phone: ( )_________________ Fax: ( )___________________

Your E-mail address: _____________________________________________

YES! I am placing my order before the cut-off date to qualify for this special reduced price offer! Please rush me the HIPAA Compliance items indicated below. I understand I have a FULL YEAR 100% NO RISK GUARANTEE and that if I am dissatisfied FOR ANY REASON - I can return my purchase for a full refund (less S&H) - NO QUESTIONS ASKED.

( ) COMPLETE "INSTANT HIPAA SECURITY COMPLIANCE KIT IN A BOX" KIT Includes ALL ITEMS described on the Web site valued at $820... - Only $299.95 plus 9.95 shipping & handling (total: $306.90)

INDIVIDUAL HIPAA PRODUCTS:

(Sorry...no Free Bonuses like above on the individual items at these low prices)

( ) "INSTANT" HIPAA SECURITY COMPLIANCE PROGRAM Only $199.95

Includes Compliance Procedures, Security Official templates, complete Risk Analysis templates, security measures, contingency plan, Complete "Security Policy & Procedure Manual" templates, the full text of the Security Rule and Security Incident Template and easy to follow instructions.

HIPAA STAFF SECURITY TRAINING PROGRAMS:

Everything you need to get your staff trained for HIPAA SECURITY AWARENESS...

( ) A. FULL "INDUSTRIAL STRENGTH" TRAINING; Includes both the Individual Training and the Group Slide Show training program

Only $199.95

( ) B. FULL "STAFF TRAINING SEMINAR ON AUDIO CD"

Only $97.95

"These publications are designed to provide accurate and authoritative information in regard to the subject matter covered. They are sold with the understanding that the publisher is not engaged in rendering legal, accounting or other professional service. If legal advice or other expert assistance is required, the services of a competent professional should be sought."

Computer requirements: PC based computer, running Windows* 98*, 2000*, ME* or XP* with Microsoft Internet Explorer* 4.0 or later. *Registered Trademarks of Microsoft Corp.
Shipping & Handling: Shipping by FAST US Priority Mail, $9.95 for all orders.

Sub Total for order: $ ____________

Shipping & Handling: $ ____________

Total Order: $ ____________

PAYMENT METHOD: ( ) Check or Money Order Enclosed ( ) Credit Card Order (complete below):

Credit Card: TYPE: ( ) M/C ( ) VISA ( ) AMERICAN EXPRESS ( ) DISCOVER

Card Number: ___________________________________ Expiration Date: ____/____

I agree to pay the above total amount according to card issuer agreement

Signature: X ____________________________________________

(Your credit card statement will show the charge to "C.C.I.-Clark Consolidated Industries, Inc.")

MAIL ORDERS: Mail to:

Clark Consolidated Industries, Inc., HIPAA Compliance Div.

9424 Darwell Drive

L.V., NV 89117-0602

FAX ORDERS: (check or credit card) - If paying by check, complete and sign your check, then

TAPE YOUR CHECK HERE

and fax to: 1-702-735-2415 (24/7)