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/ BMUG PD-ROM 1995 Fall / PD-ROM F95.toast / BMUG Essentials / BMUG Membership Form.txt < prev    next >
Text File  |  1994-12-19  |  693b  |  26 lines
  1.  
  2. Name: ___________________________________   Date: ___/___/___   
  3.                                                                
  4. Company Name:    ____________________________________________
  5.         
  6. Address:    _________________________________________________
  7.         
  8. City:    __________________________ State: ________  Zip: ________
  9.  
  10. Country: _________________  Day Phone:    (______)______-________
  11.  
  12. ___ Cash
  13. ___ Check/Money Order
  14. ___ Credit Card
  15.  
  16. MasterCard/VISA# (please print) ______________________________
  17.      
  18. Expiration Date: ___/___   Signature:  ________________________
  19.  
  20. __ New Member
  21. __ Renewal
  22. __ Change of Address
  23.  
  24. $28 - 6 month membership
  25. $45 - 1 year individual membership
  26. $80 - 1 year family membership