date           
                                                       ___________

                                                                  
                      ____________________________________________
                                          name

                                                                  
                      ____________________________________________
                                         address

                                                                  
                        _______________________  ___  ____________
                                city            state     zip

                                                                  
                      _____ ______________   ____  _______________
                      areacode    phone          alternate phone

                     type of computer                             
                                      ____________________________
                     hard disk y/n?           capacity?           
                                      _____             __________

                     where did you learn of DEX-i-cal?/comments
                                                                   
                     ______________________________________________

                                                                   
                     ______________________________________________

                                                                   
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