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Product Information MedEx Data Sheet Patient Signature Capture Data Sheet Advanced Labeling Data Sheet Image Integration Data Sheet Bottomline Print Manager Data Sheet Recent News 08.24.10  Bottomline Technologies Awarded U.S. Patent for Invoice Data Capture Capabilities 08.12.10  Bottomline Technologies Reports Fourth Quarter Results 08.10.10  Bottomline to Share Order-to-Pay Automation Expertise at JD Edwards Educational Conference 08.03.10  Bottomline Technologies’ Expertise in Cloud Computing Highlighted at Premier Cash Management Forum 06.15.10  Bottomline Technologies to Present at Upcoming Investor Conference 06.04.10  Bottomline Technologies Prices Underwritten Public Offering of Common Stock 06.03.10  Bottomline Technologies Announces Proposed Public Offering of Common Stock 05.18.10  Bottomline Technologies to Present at Upcoming Investor Conferences	Healthcare Autodemos Thank you for your interest in Bottomline's healthcare forms automation solution. To view Bottomline's healthcare autodemos now, please complete the following information. All fields shown in bold are required to process this form. Yes! Add me to your mailing list.  (See Privacy Policy for more information) First Name: Last Name: Organization: Title: Address: Address (cont'd): City: State/Province: Select State Not Applicable AB - Alberta AK - Alaska AL - Alabama AR - Arkansas AZ - Arizona BC - British Columbia CA - California CO - Colorado CT - Connecticut DC - District of Columbia DE - Delaware FL - Florida GA - Georgia HI - Hawaii IA - Iowa ID - Idaho IL - Illinois IN - Indiana KS - Kansas KY - Kentucky LA - Louisiana MA - Massachusetts MB - Manitoba MD - Maryland ME - Maine MI - Michigan MN - Minnesota MO - Missouri MS - Mississippi MT - Montana NB - New Brunswick NC - North Carolina ND - North Dakota NE - Nebraska NH - New Hampshire NJ - New Jersey NL - Newfoundland and Labrador NM - New Mexico NS - Nova Scotia NT - Northwest Territories NU - Nunavut NV - Nevada NY - New York OH - Ohio OK - Oklahoma ON - Ontario OR - Oregon PA - Pennsylvania PE - Prince Edward Island PR - Puerto Rico QC - Quebec RI - Rhode Island SC - South Carolina SD - South Dakota SK - Saskatchewan TN - Tennessee TX - Texas UT - Utah VA - Virginia VT - Vermont WA - Washington WI - Wisconsin WV - West Virginia WY - Wyoming YT - Yukon Headquarters*: Select State Not Applicable AB - Alberta AK - Alaska AL - Alabama AR - Arkansas AZ - Arizona BC - British Columbia CA - California CO - Colorado CT - Connecticut DC - District of Columbia DE - Delaware FL - Florida GA - Georgia HI - Hawaii IA - Iowa ID - Idaho IL - Illinois IN - Indiana KS - Kansas KY - Kentucky LA - Louisiana MA - Massachusetts MB - Manitoba MD - Maryland ME - Maine MI - Michigan MN - Minnesota MO - Missouri MS - Mississippi MT - Montana NB - New Brunswick NC - North Carolina ND - North Dakota NE - Nebraska NH - New Hampshire NJ - New Jersey NL - Newfoundland and Labrador NM - New Mexico NS - Nova Scotia NT - Northwest Territories NU - Nunavut NV - Nevada NY - New York OH - Ohio OK - Oklahoma ON - Ontario OR - Oregon PA - Pennsylvania PE - Prince Edward Island PR - Puerto Rico QC - Quebec RI - Rhode Island SC - South Carolina SD - South Dakota SK - Saskatchewan TN - Tennessee TX - Texas UT - Utah VA - Virginia VT - Vermont WA - Washington WI - Wisconsin WV - West Virginia WY - Wyoming YT - Yukon *What state/province is your company’s headquarters located in? Country: Select Country Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua And Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia And Herzegowina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote D'Ivoire Croatia (Local Name: Hrvatska Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard And McDonald Islands Holy See (Vatican City State Honduras Hong Kong Hungary Iceland India Indonesia Iran (Islamic Republic Of) Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, Dem People's Republic Korea, Republic Of Kuwait Kyrgyzstan Lao People's Dem Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States Moldova, Republic Of Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Ant Illes New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Kitts And Nevis Saint Lucia Saint Vincent, The Grenadines Samoa San Marino Sao Tome And Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia (Slovak Republic) Slovenia Solomon Islands Somalia South Africa South Georgia , S Sandwich Is. Spain Sri Lanka St. Helena St. Pierre And Miquelon Sudan Suriname Svalbard, Jan Mayen Islands Sw Aziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania, United Republic Of Thailand Togo Tokelau Tonga Trinidad And Tobago Tunisia Turkey Turkmenistan Turks And Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Is. Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wallis And Futuna Islands Western Sahara Yemen Yugoslavia Zaire Zambia Zimbabwe Zip/Postal Code: Phone Number: E-mail: 1. Number of hospitals? 2. Number of beds? Please select Less than 25 25 - 100 More than 100 3. Areas of interest (check all that apply): Forms Replacement Document Automation Enterprise Distribution Barcode Patient Documents Checks & Electronic Payments Fax Automation Web Presentment & Notification HL7 Interconnectivity XML Delivery Materials Management 4. Primary software application (check one): Cerner Cycare Eclipsys McKesson IDX Medic Meditech Siemens Other          5. What is your project timeline? We are actively looking for a solution provider and plan to purchase in the next 6-12 months. We have a budget and plan to issue an RFP/RFI soon. We have secured a budget, but do not yet have a timeframe for purchase. We do not have a project scheduled at this time. 6. Comments:    Use this space to tell us more about your organization.  Feel free to include any other information which would help our healthcare solutions experts and services personnel to best support the needs of your facility and/or data center.

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