PERSONNEL DEPT.> OFFICIAL COMPANY ORDER FORM No:____________

TOTAL COMPANY EMPLOYEE BENEFIT

ANNUAL CONTRIBUTION CONTRIBUTION COST

BENEFIT

Retirement Plan $............ $............ . .......

Deferred Compen. $............ $............ . .......

Incentive Stock Op. $............ $............ . .......

Disability Insur. $............ $............ . .......

Health Insurance $............ $............ . .......

Group Life Insur. $............ $............ . .......

Dental Insurance $............ $............ . .......

Education Benf. $............ $............ . .......

Profit - Sharing $............ $............ . .......

Performance Bonus $............ $............ . .......

Scholarship Aid $............ $............ . .......

Relocation Expense $............ $............ . .......

Group Legal $............ $............ . .......

Wage Continuation $............ $............ . .......

Child Care $............ $............ . .......

Club Memberships $............ $............ . .......

Stock Options $............ $............ . .......

Stock Purchase Plan $............ $............ . .......

Pai-Up Annuities $............ $............ . .......

Low-Interest Loans $............ $............ . .......

Company Car $............ $............ . .......

Financial Counsel. $............ $............ . .......

Other: $............ $............ . .......

* This Form is to be kept on file - PERSONNEL DEPARTMENT.