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/ Monster Media 1996 #14 / Monster Media No. 14 (April 1996) (Monster Media, Inc.).ISO / games / assimil8.zip / ORDER.FRM < prev    next >
Text File  |  1995-10-29  |  2KB  |  52 lines
  1.                        ==============================
  2.                        ASSIMILATION REGISTRATION FORM
  3.                        ==============================
  4.  
  5.                YES, I'd like to receive registered Assimilation!
  6.  
  7.                   Return completed form via mail, or e-mail!
  8.  
  9.  
  10.             NAME:_____________________________________________________
  11.  
  12.          ADDRESS:_____________________________________________________
  13.  
  14.                  _____________________________________________________
  15.  
  16.             CITY:________________________ STATE/PROV:_________________
  17.  
  18.         ZIP CODE:____________________ PHONE/FAX:______________________
  19.  
  20.                                         COUNTRY:_______________
  21.  
  22.                                       Canadian orders: $13.00 per copy
  23.                                           U.S. orders: $10.00 per copy
  24.  
  25.                 Method of receiving Assimilation:
  26.                 3 1/2" floppy _____  or  uuencoded email _____
  27.  
  28. ** Shipping & Handling is included in price!
  29.  
  30.                       Canadian ORDERS:  _____ copies @ $13.00 ea : _______
  31.  
  32.                           U.S. ORDERS:  _____ copies @ $10.00 ea : _______
  33.  
  34.                                                 >> TOTAL PAYMENT : _______
  35.  
  36.                             
  37.  
  38. PAYMENT TYPE: ( ) Check  ( ) Money Order
  39.  
  40.           Make orders payable to Perry Robertson
  41.  
  42.            ALL ORDERS GO TO:
  43.             Perry Robertson
  44.             156 Chartwell Drive, Apt. 103
  45.             Sault Ste. Marie, ON, Canada
  46.             P6A 6A2
  47.  
  48.    E-mail:  perry.robertson@csrnet-bbs.com
  49.  
  50. ** Do not send cash in the mail!
  51.  
  52.