Lode Doomer ordering form
-------------------------

If you do not have access to the Internet, you can register via
phone, fax or postal mail. Please print out the following form,
and fax or mail it to:

 Register Now!
 Dept# 8458-1
 PO Box 1816
 Issaquah, WA 98027
 United States of America 

 Phone:
      Toll Free: 877-353-7297
      Regular:   425-392-2294
 Fax:
      Toll Free: 888-353-7276
      Regular:   425-392-0223


Personal Information
  Program No.: 8458-1
  First Name:      ___________________________________________
  Last Name:       ___________________________________________
  Company:         ___________________________________________
  Street Address:  ___________________________________________
  City:            ___________________________________________
  State/Province:  ___________________________________________
  Zip/Postal Code: ___________________________________________
  Country:         ___________________________________________
  Phone:           ___________________________________________
  Email Address:   ___________________________________________
 
Order Information  
  Quantity: ______
  Price:  $15
 
Payment Information  
  Name on Card: _____________________________
  Type of Credit Card: ______________________
  Card Number: ___________________
  Expiration Date:  Month ________ Year(4 digits) _______