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BMTMICRO.FOR
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1996-04-19
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59 lines
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BMT Micro
FastLst Registration Form
*****************************************
* DO NOT SEND this form to the author ! *
*****************************************
See Register.Doc for instructions, please PRINT: Date: __/__/__
Name: ____________________________________________________________
Company: _________________________________________________________
Address: _________________________________________________________
__________________________________________________________________
City: _______________________ State/Province: __________________
Country: ____________________________ Postal Code: _______________
Phone: ___________________________________________________________
Fax: _____________________________________________________________
REGISTRATION INFORMATION
Reg.: ____________________________________________________________
e-mail to: _______________________________________________________
Netmail to: ______________________________________________________
Crash to: ________________________________________________________
Product: FastLst (by Alberto Pasquale) Price: US$ 25.00
North Carolina residents, please add 6% sales tax: +US$ 1.50
Total: US$ __.__
For credit card payment only:
Circle one: VISA / Master / Discover / AMEX / Diner's Club
Credit card number : _________________________________________
Expiration date : ___/___
Authorization signature: _________________________________________
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