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Text File  |  1996-11-15  |  2KB  |  52 lines
  1. --------------------------------------------------------------------------
  2.                           BRAIN DRAIN V1.3 ORDER FORM
  3. --------------------------------------------------------------------------
  4.  
  5. YOUR NAME OR BBS NAME: ___________________________________________________
  6.                        (EXACTLY as it should appear in registration line)
  7. POSTAL ADDRESS : ______________________________________________________
  8.  
  9.                  ______________________________________________________
  10.  
  11. VOICE PHONE NUMBER : ______________________
  12.  
  13. E-MAIL ADDRESS :     ____________________________________   (IF APPLICABLE)
  14.  
  15. BBS PHONE NUMBER :   ______________________                 (IF APPLICABLE)
  16.  
  17. FIDONET ADDRESS:     ____________________________________   (IF APPLICABLE)
  18.  
  19. SEND MY REGISTRATION VIA:
  20.           ___
  21.          |   | - CONVENTIONAL MAIL
  22.          |___|
  23.           ___
  24.          |   | - INTERNET E-MAIL
  25.          |___|
  26.           ___
  27.          |   | - FIDONET "NETMAIL"
  28.          |___|
  29.  
  30.  
  31. MAKE CHECK ($15 U.S.) PAYABLE TO:  ROBERT CHAMBERS
  32.  
  33. MAIL PAYMENT TO:  14645 COTTAGE OAK AVENUE
  34.                   BATON ROUGE, LA  70810
  35.  
  36.  
  37. +-- OFFICIAL USE ONLY ----------------------------------+
  38. |                                                       |
  39. | Rcvd : _______  Date : _________  Key : _____________ |
  40. +-------------------------------------------------------+
  41.  
  42. ANY COMMENTS OR SUGGESTIONS?:
  43. ___________________________________________________________________________
  44. ___________________________________________________________________________
  45. ___________________________________________________________________________
  46. ___________________________________________________________________________
  47. ___________________________________________________________________________
  48. ___________________________________________________________________________
  49.  
  50. THANKS FOR YOUR ORDER!
  51.  
  52.