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  1.  
  2.     HomeBank Registration Form
  3.     ==========================
  4.  
  5.     To:
  6.  
  7.     Maxime DOYEN
  8.     A2/12 Rés. Planche Epinoy
  9.     59170 Croix
  10.     France
  11.  
  12.     Registration Informations:
  13.     --------------------------
  14.  
  15.      Name: FirstName FamilyName                
  16.            ¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯
  17.    Street: Nr., Street, District               
  18.            ¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯
  19.  ZIP,City: PostalCode, City, County            
  20.            ¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯
  21.   Country: England            
  22.            ¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯
  23.     Phone: +44-000-000-0000   
  24.            ¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯
  25.     EMail: user@host.domain                      
  26.            ¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯
  27.  
  28.     HomeBank Registration Amount (Only Cash: FF, DM, £, US$):
  29.     ---------------------------------------------------------
  30.     +-+
  31.     | | 100 FF Cash (or eq. DM, £, US$) - Receive via E-Mail
  32.     +-+
  33.     | | 120 FF Cash (or eq. DM, £, US$) - Receive on 3,5" DD via Slow Mail
  34.     +-+
  35.  
  36.   Optional comments:
  37.  
  38.                                                                     
  39.   ¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯
  40.                                                                     
  41.   ¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯
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  43.   ¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯
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  46.  
  47.  
  48.     I have read the copyright details and agree.
  49.  
  50.  
  51.  
  52.    ¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯         ¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯
  53.             (City, Date)                           (Signature)
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