Toshiba National Accounts Application Form:

YOUR COMPANY NAME:

* DECISION MAKER'S FIRST NAME

* DECISION MAKER'S LAST NAME

* ADDRESS LINE 1

ADDRESS LINE 2

* CITY * STATE -- AB AK AL AR AZ BC CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MB MD ME MI MN MO MS MT NB NC ND NE NF NH NJ NM NS NT NU NV NY OH OK ON OR PA PE QC RI SC SD SK TN TX UT VA VT WA WI WV WY ZIP CODE

PHONE NUMBER FAX NUMBER

* DO YOU CURRENTLY USE CENTRALIZED PURCHASING? SELECT ONE YES NO

* DO YOU CURRENTLY USE TOSHIBA SYSTEMS? SELECT ONE YES NO

WHICH OTHER SYSTEMS ARE YOU CONSIDERING?

* TYPE OF INDUSTRY? -- Academic Accounting Advertising Animal Boarding Svcs Assisted Living Automotive Banking Building & Mechanical Contractors Childcare Computer Technology Consultant Education Engineering Entertainment Financial / Leasing Food Food Products Government Health Care Home Building Hotel/Motel Information Services Inn-Keepers Insurance Investment Brokers Land Developers Lawyers Manufacturing Media (TV & Radio) Military Municipal Government Notes Alliance Partner Oil Package Delivery Personnel Pharmaceutical Publishing/Printing Real Estate Religious Retailing Technology Telecommunications Transportation Travel Agencies Unions / Labor Organiz. Utilities Veterinary Svcs Waste Mgmt Wholesale

* WHAT TYPE OF ISSUES DO YOU HOPE TO SOLVE?

OTHER COMMENTS

* ESTIMATED ANNUAL TELEPHONE SYSTEM PURCHASES $

* NUMBER OF LOCATIONS YOUR COMPANY HAS

* DEADLINE FOR FIRST INSTALLATION: Select Month 01 02 03 04 05 06 07 08 09 10 11 12 Select Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Select Year 2006 2007 2008

* HOW LIKELY ARE YOU TO IMPLEMENT A TOSHIBA SOLUTION WITHIN THE NEXT TWO MONTHS? SELECT ONE 25% 50% 75% 95% 101%