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Text File  |  1994-03-23  |  1KB  |  40 lines

  1.                         
  2.  
  3.                                 Registration Form
  4.  
  5.  
  6. Name: ________________________________________________________________
  7.  
  8. Street: ______________________________________________________________
  9.  
  10. City: ____________________ State: ______ Zip code: ___________________
  11.  
  12. Country: _____________________________________________________________
  13.  
  14. Phone: _______________________________________________________________
  15.  
  16. Program registering: _________________________________________________
  17.  
  18. Type of disk: 3 1/2: ____________________ 5 1/4: _____________________
  19.  
  20. Computer: ____________________________________________________________
  21.  
  22. On-line service or BBS's: ____________________________________________
  23.  
  24. ______________________________________________________________________
  25.  
  26. Where did you get the program: _______________________________________
  27.  
  28. ______________________________________________________________________
  29.  
  30. Amount enclosed: _____________________________________________________
  31.  
  32.  
  33.  
  34.  
  35. Send to:
  36.                 
  37.                 Burnham Park Software, Inc.
  38.                 P.O. Box #814
  39.                 Chicago, IL 60690-0814
  40.