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#             Backer Registration Card              #
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Name_______________________________________________________________

Address_____________________________________________________________

City__________________________ State ____________________ZIP________

Country________________________E-mail ______________________________

•___ I want to receive my registration number by E-Mail.

I register my Backer copy, version ___.___ 

My payment :         
     Mode
                 ____ cash
                 ____ check

    Currency

____  US $ 20
                 ____  100 French Francs
                 ____  13 British Pounds
                 ____  30 German D-Mark
                 ____  Canadian $ 28
                 ____  2100 Yen

Date : ___________________________ Signature_________________________ 

•The way I've got Backer :
___________________________________________________________________________

___________________________________________________________________________

•My remarks:
___________________________________________________________________________

___________________________________________________________________________

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Mail to

:       
              
M Didier & Olivier GUILLION
               36 rue de la Jeunesse
               31200 Toulouse 

FRANCE