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/ Monster Media 1996 #15 / Monster Media Number 15 (Monster Media)(July 1996).ISO / utils / dupe_n25.zip / REG-FORM.TXT < prev    next >
Text File  |  1996-05-29  |  3KB  |  47 lines
  1.  
  2.                          DUPE NUKEM Registration Form
  3.  
  4. Name _________________________________________________________________________
  5.  
  6. Address ______________________________________________________________________
  7.  
  8. City ________________   Province/State ___________   Postal/Zip Code _________
  9.  
  10. Country _________   Phone # - Voice ___________________ Data _________________
  11.                                                    
  12. How would you like your key sent?  (As soon as Cheque clears... 8) )
  13.         
  14.         (  )  Postal Mail    -    (  ) 3-1/2 inch     (  ) 5-1/4 inch Diskette
  15.                              (* Please add $5 P&H *)
  16.         (  )  Fido Crash/Netmail  - Address:
  17.         (  )  Internet UUEncoded  - Address:
  18.         (  )  Download from my BBS  (Will be available under your FULL NAME)
  19.                   Password for your account:_________________
  20.  
  21. NOTE:  Please be sure to make out Cheque or M.O. (preferably), for $15, to:
  22.  
  23.        ALLEN WALKER, P.O. Box 5874,  Victoria, B.C, Canada,  V8R 6S8
  24.  
  25. ┌─────────────────────────────────────────────────────────────────────────────┐
  26. │   If you want to pay for the door by VISA, I will need the following info:  │
  27. │                                                                             │
  28. │ Name (exactly as on Card): ________________________________________________ │
  29. │                                                                             │
  30. │ Visa Number: __________________________________    Expiry date: ___________ │
  31. │                                                                             │
  32. │   Since the VISA is charged in Canadian Funds, the following amounts apply: │
  33. │                                                                             │
  34. │                          Canadian Orders:  $15.OO                           │
  35. │                          U.S.     Orders:  $19.OO                           │
  36. │                                                                             │
  37. │                         Postage & Handling:  $5.OO                          │
  38. │         (P&H only applies to me mailing you your Registration & Disk)       │
  39. │                                                                             │
  40. │                         Total Charge: $___________                          │
  41. │                                                                             │
  42. └─────────────────────────────────────────────────────────────────────────────┘
  43. Comments/Suggestions:
  44.  
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