[--GalaxyNET Channel Registration Form--]

** READ THIS PLEASE! **
** Important Instructions **

1. Please fill out the attached form as much as possible, anything left
   blank will be discarded and your channel will not be registered.

2. Cut at the appropiate line and paste into the message TEXT to :
   channel-registration@galaxynet.org

3. While your channel is being viewed, Please enjoy one of the many
   GalaxyNet Servers, or take this time to learn Q's many commands.

--------------------------------cut here-----------------------------------

A. 1. The Nickname you usually go by (e.g. Butch): 
   2. The Nickname you registered as on Q/NickServ: 

B. Your Email address (e.g. foo@bar.com):

C. Channel you wish to register (e.g. #camelspit):  

D. Please list 5 IRC Nicknames and their E-Mail Addresses who will directly
   support your request and frequent the channel which you have requested. 
   ---------------------------------------------------------------
   		Nickname	|	E-mail address                  
   ---------------------------------------------------------------
	1. 

	2. 
	
        3.  

	4.

	5.

E. Please right a short statement as to the purpose of this channel, and
   why you feel it should be yours: