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  1.                          QMPLOG Registration Form
  2.                          
  3.  First Name:__________________________________________
  4.  Last Name:___________________________________________
  5.  Name to Register Program under:______________________
  6.  Address:_____________________________________________
  7.          _____________________________________________
  8.  City:________________________________________________
  9.  State:_______________________________________________
  10.  Zipcode:_____________________________________________
  11.  Phone:_______________________________________________
  12.  Version of QMPLOG:___________________________________
  13.  
  14.  [ ] Yes, I want a user account on your board. Here is my info
  15.      Handle:__________________________________________
  16.      2nd Choice:______________________________________
  17.      3rd Choice:______________________________________
  18.      Password:________________________________________
  19.      Birthday:________________________________________
  20.      Occupation:______________________________________
  21.  
  22.  [ ] I am a Sysop of a BBS
  23.      Board Name:______________________________________
  24.      Number:__________________________________________
  25.      Max Baud:________________________________________
  26.      Software:________________________________________
  27.      Hours:___________________________________________
  28.      
  29.  [ ] I am enclosing $5 extra for a disk with the latest version on it
  30.      Disk Format  [ ] 3.5HD  [ ] 5.25HD
  31.  
  32. Comments:___________________________________________________________
  33. ____________________________________________________________________
  34. ____________________________________________________________________
  35. Features you would like to see added:_______________________________
  36. ____________________________________________________________________
  37. ____________________________________________________________________
  38.  
  39.  Send this form with $10 (or $15 for disk) check, money order, or cash to:
  40.  
  41.      QMPLOG Registration
  42.      c/o Joel Alt
  43.      900 Westgate Drive, Apt B-10
  44.      Bossier City, LA  71112-3540
  45.  
  46.  Please allow 4 to 6 weeks for registration key
  47.  Check orders will not be processed until check clears the bank.
  48.