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Text File  |  1993-07-16  |  1KB  |  47 lines
  1.  
  2.  
  3.                         Registration Form For Purge v2.1
  4.                         ────────────────────────────────
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  7.                Your Full Name ________________________________________
  8.  
  9.                Street Address ________________________________________
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  11.              City, State, Zip ________________________________________
  12.  
  13.            Voice Phone Number ________________________________________
  14.                (Optional)
  15.              Name of Your BBS ________________________________________
  16.  
  17.              BBS Phone Number ________________________________________
  18.  
  19.          Comments/Suggestions ________________________________________
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  21.          _____________________________________________________________
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  23.          _____________________________________________________________
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  25.          _____________________________________________________________
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  27.          _____________________________________________________________
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  30.          Cost for registration is $20.00  Please make checks payable
  31.          to Ray Novino and mail to:
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  33.                                    Ray Novino
  34.                                    PO Box 0941
  35.                                    Lansdowne, PA 19050
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  38.          We also Accept Visa, Master Card and Dinners Club
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  40.          Credit Card Number __________________________________________
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  42.             Expiration Date ________________________
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  44.    Signature of Card Holder __________________________________________
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