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Text File  |  1990-12-23  |  1KB  |  32 lines
  1.                     Micro TECH Systems Registration form
  2.  
  3. Remit To:           Micro TECH Systems, Inc.
  4.                     555 North Spring, #39
  5.                     Cape Girardeau Mo. 63701
  6.  
  7. Ymodem Batch/ Ymodem-G..............................  $ 15.00 [ ]
  8.  
  9. Payment by:  Check (U.S. bank or branch) enclosed [ ]    MC [ ]     VISA [ ]
  10.  
  11. Use Address on check [ ]  envelope [ ]   or:
  12.  
  13. Name     ___________________________________________________________________
  14.  
  15. Address  _________________________________________________________
  16.  
  17.          ___________________________________________________________________
  18.  
  19.          ___________________________________________________________________
  20.  
  21.          ..... Following only needed for Credit Card
  22.  
  23. Work Phone  (____) __________________  Home Phone   (____)  ________________
  24.  
  25. Card #  _____________________________________________  Expires _____________
  26.  
  27. Name of Cardholder  ________________________________________________________
  28.  
  29. Signature __________________________________________________________________
  30.  
  31.  
  32.