ComputerDIET Analyzer for Windows 95 -- User Registration Form

1. User information:

Name: ___________________________________________________________
Address: ________________________________________________________
City: ___________________ State: _____________ ZIP: _____________
Country (if other than U.S.A.):__________________________________
Phone number: (___)______________ Date (MM/DD/YY): ____/____/____
E-mail address (optional): ______________________________________

2. Payment and fees:

Fees are in U.S. dollars, please do not send cash. Checks and
money orders must be made payable to Interactive Outfitters.
Select form of payment (check one):

__ Enclosed check or money order in U.S. dollars
__ Credit card payment: ___ VISA   ___ MasterCard    
   Card Number: ______________________________
   Expiration Date (MM/YY): ____/____
   Signature ________________________

3. Check all that apply and fill in the blanks:

__ One registered copy of ComputerDIET Analyzer............$39.00
__ U.S. Shipping and handling..............................$ 5.00
__ Colorado residents add appropriate sales tax............$_____

Total:.....................................................$_____

4. Mail this form together with payment to:

   Interactive Outfitters
   ComputerDIET Analyzer Registration
   P.O. Box 7215
   Loveland, CO 80537-0215
   USA