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Text File  |  1996-04-02  |  2KB  |  57 lines
  1. GTI WordGrid Registration Form  
  2. ==============================
  3.  
  4.  
  5. Name:        ________________________________________________________________
  6.  
  7. Address:     ________________________________________________________________
  8.  
  9.          ________________________________________________________________
  10.  
  11.          ________________________________________________________________
  12.  
  13. City:        ________________________________________________________________
  14.  
  15. Zip/Post Code:    ________________          State/Country: ____________________
  16.  
  17. E-Mail:        ________________________________________________________________
  18.  
  19. Please send me :-
  20.                  (US)    Sub Total
  21. _____ Copies GTI WordGrid     $20.00      _____
  22.  
  23.     Shipping        $4.00      $4.00
  24.  
  25.        TAX  (NYS residents only) ___ %      _____
  26.  
  27.                   Total Enclosed is ___________
  28.  
  29. I am paying by:
  30. ( ) CHECK     ( ) VISACARD    ( ) MASTERCARD     ( ) AMERICAN EXPRESS
  31. ( ) CASH  (by registered mail only, please)      ( ) DISCOVER CARD
  32.  
  33. Card Number ______-______-______-______  Exp. date ___-___
  34.  
  35. ________________________________________________      ______-______-______
  36. (Signature)                                           (Date)
  37.  
  38. Make checks payable to: Pik A Program
  39. Where did you hear about GTI WordGrid ?
  40. ______________________________________________________________________________
  41.  
  42. Comments:   __________________________________________________________________
  43.  
  44. ______________________________________________________________________________
  45.  
  46. ______________________________________________________________________________
  47.  
  48. ______________________________________________________________________________
  49.  
  50.  
  51. Send your completed order to:    Pik A Program
  52.                  13 Saint Marks Place
  53.                  NY, NY  10003
  54.             
  55. Tel 1-800-TOREGISTER  (1-800-867-3447) or (212) 598-4939
  56. Fax (212) 228 5879          E-Mail 74777.3233@compuserve.com
  57.