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/ Monster Media 1996 #14 / Monster Media No. 14 (April 1996) (Monster Media, Inc.).ISO / graphics / mag02.zip / ORDER.FRM < prev    next >
Text File  |  1996-03-09  |  1KB  |  47 lines
  1.  
  2.  
  3.                             MAG Registration Form
  4.  
  5.         Date:           ____________________________________________
  6.  
  7.         Name:           ____________________________________________
  8.  
  9.         Address:        ____________________________________________
  10.  
  11.                         ____________________________________________
  12.  
  13.         City/State:     ____________________________________________
  14.  
  15.         Country:        ______________________   Zip: ______________
  16.  
  17.         E-Mail address: ____________________________________________
  18.  
  19.                         ____________________________________________
  20.  
  21.                         ____________________________________________
  22.  
  23.  
  24.         Telephone:      (________)  _________ - ____________________
  25.  
  26.  
  27.         Comments and Suggestions:
  28.  
  29.         ____________________________________________________________
  30.  
  31.         ____________________________________________________________
  32.  
  33.         ____________________________________________________________
  34.  
  35.  
  36.         Total enclosed                            $US _20.00______
  37.  
  38.         
  39.         Mail completed form with cash, check or money order payable to
  40.         Mark Gauthier at:
  41.  
  42.                        MAG / Mark Gauthier
  43.                        58 Emilien-Frenette
  44.                        Sainte-Therese, PQ, Canada.
  45.                        J7E 5K3
  46.  
  47.